CARDIOVASCULAR DISEASE SERIES
Number 27
Medicines for cardiovascular
health: are they used
appropriately?
Susana Senes
Elizabeth Penm
May 2007
Australian Institute of Health and Welfare
Canberra
AIHW cat. no. CVD 36
© Australian Institute of Health and Welfare 2007
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be
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Requests and enquiries concerning reproduction and rights should be directed to the Head,
Business Promotion and Media Unit, Australian Institute of Health and Welfare, GPO Box 570,
Canberra ACT 2601.
This publication is part of the Australian Institute of Health and Welfare’s Cardiovascular disease series.
A complete list of the Institute’s publications is available from the Institute’s website <www.aihw.gov.au>.
ISSN 1323-9236
ISBN 978 1 74024 689 7
Suggested citation
Australian Institute of Health and Welfare: Senes S and Penm E 2007. Medicines for cardiovascular
health: are they used appropriately? Cardiovascular disease series no. 27. Cat. no. 36. Canberra: AIHW.
Australian Institute of Health and Welfare
Board Chair
Hon. Peter Collins, AM, QC
Director
Penny Allbon
Any enquiries about or comments on this publication should be directed to:
Susana Senes
Australian Institute of Health and Welfare
GPO Box 570
Canberra ACT 2601
Phone: (02) 6244 1000
Email: [email protected]
Published by the Australian Institute of Health and Welfare
Printed by Union Offset
Please note that as with all statistical reports there is the potential for minor revisions of data in this
report over its life. Please refer to the online version at <www.aihw.gov.au>.
Contents
Acknowledgments............................................................................................................................... v
Key points ...........................................................................................................................................vii
1
Introduction ...................................................................................................................................1
2
Background ....................................................................................................................................2
2.1 Quality use of medicines.......................................................................................................2
2.2 Opportunities and challenges for quality use of medicines ............................................3
2.3 Medicines and cardiovascular disease................................................................................5
3
Use of cardiovascular medicines for any health condition...................................................9
3.1 Supply of cardiovascular medicines in the community ...................................................9
3.2 Cardiovascular medicines prescribed in general practice..............................................15
4
Use of medicines for cardiovascular disease .........................................................................18
5
Quality use of cardiovascular medicines ...............................................................................20
5.1 Medicines prescribed for cardiovascular disease ............................................................20
5.2 Concordance with medicines .............................................................................................27
5.3 National Prescribing Service initiatives ............................................................................35
5.4 National Institute of Clinical Studies initiatives..............................................................37
5.5 National Primary Care Collaboratives..............................................................................38
5.6 Section 100 initiative ............................................................................................................39
5.7 Drug-adverse events............................................................................................................39
6
Expenditure on cardiovascular medicines .............................................................................45
7
Discussion ....................................................................................................................................48
Appendix..............................................................................................................................................52
Appendix tables ...........................................................................................................................52
Appendix figures .........................................................................................................................56
The Anatomical Therapeutic Chemical (ATC) classification system ...................................58
Data sources..................................................................................................................................63
Methods.........................................................................................................................................64
National bodies with responsibility for quality use of medicines ........................................71
Glossary................................................................................................................................................73
iii
References............................................................................................................................................76
List of tables ........................................................................................................................................80
List of figures ......................................................................................................................................81
iv
Acknowledgments
This report was prepared by Susana Senes and Elizabeth Penm of the National Centre for
Monitoring Cardiovascular Disease at the Australian Institute of Health and Welfare
(AIHW).
We are grateful for assistance with the conceptual design of this report given by Sharon
Leigh (formerly at AIHW) and members of the Heart, Stroke and Vascular Health Data
Working Group, which includes Andrew Tonkin (Monash University), Andrew Boyden
(National Heart Foundation), Alan Cass (The George Institute for International Health),
Annette Dobson (University of Queensland), Jeff Flack (Bankstown–Lidcombe Hospital),
Noel Hayman (Queensland Health), Michael Hobbs (University of Western Australia),
Catriona Bate (Australian Bureau of Statistics), Paul Magnus (AIHW), Richard McCluskey
(Heart Support Australia), Suzanne Prosser (Department of Health and Ageing), Lynelle
Moon (AIHW), Ian Ring (University of Wollongong), Mandy Thrift (Baker Heart Research
Institute) and Gavin Turrell (Queensland University of Technology).
Many thanks to Ying Pan for extracting data from the BEACH study and to Chris Raymond,
Andrew Kopras, John Dudley, Maxine Robinson, Vanna Mabbott and Ian Titulaer for
supplying data on Pharmaceutical Benefits Scheme medicines and advice on their use. Terry
Neeman and Chris Stevenson gave guidance on statistical methods.
Valuable comments were provided by Andrew Boyden (National Heart Foundation of
Australia), Helena Britt (University of Sydney), Annette Dobson (University of Queensland),
Garry Jennings (Baker Heart Research Institute), Mike Langan (Australian Bureau of
Statistics), Paul Magnus (AIHW), Lynelle Moon (AIHW), Jane Reuter (AIHW), Elizabeth
Roughead (University of South Australia), Emma Slaytor (National Prescribing Service),
Mandy Thrift (Baker Heart Research Institute), Andrew Tonkin (Monash University), Lynn
Weekes (National Prescribing Service) and the Pharmaceutical Health and Rational Use of
Medicines (PHARM) Committee.
The AIHW gratefully acknowledges funding from the Australian Government to contribute
to the production of this report.
v
vi
Key points
This report draws on a range of sources to present national information on the use of
medicines to prevent and treat heart, stroke and vascular disease (cardiovascular disease).
It covers trends in prescription and supply of these medicines, patterns of supply by
geographic area and patient socioeconomic level, whether patients take medicines as
intended, adverse events associated with these medicines, initiatives to improve the quality
of use of medicines and government expenditure on cardiovascular medicines.
Encouraging news
• Increasing use of ‘best practice’ is suggested by steady rises between 2000 and 2006 of
prescriptions for the following:
− cholesterol-lowering agents (statins) in coronary heart disease and diabetes
− certain blood-pressure-lowering medicines (agents acting on the renin–angiotensin
system) in hypertension and diabetes
− clot-preventing medicines in coronary heart disease
− beta-blocking agents in heart failure.
• People in the most socioeconomically disadvantaged group, who are at greater risk of
cardiovascular disease, were dispensed cholesterol-lowering agents (statins) and some
clot-preventing medicines at a higher rate than those in the least disadvantaged group.
Concerns
• Many people stop taking medicines that should be taken long-term to prevent or treat
cardiovascular disease.
• Compared with those in major cities, people in rural and remote areas have higher death
rates from cardiovascular disease, but are dispensed these medicines at:
− half the rate in rural areas
− about one-thirtieth the rate or less in remote areas.
• Adverse effects of these medicines were associated with 301 deaths and almost 28,500
hospitalisations in 2004.
More work needs to be done
• Some improvements were small and treatment gaps remain in coronary heart disease,
stroke, heart failure and hypertension.
• The best data sources available are inadequate to fully assess whether medicines are used
appropriately. The capacity to link health records to track information on individuals
within and between datasets would support analysis of quality use of medicines and
enhance patient safety.
vii
1 Introduction
The National Chronic Disease Strategy calls for support for the appropriate use of medicines
to maximise health outcomes and quality of life. This report aims to inform policy on chronic
disease prevention and care regarding cardiovascular disease in Australians. Specifically, it
attempts to shed some light on the question ‘Are medicines to prevent and treat cardiovascular
disease used appropriately?’ by presenting information from a range of data sources to cover
various aspects of using medicines well.
The Background chapter of the report introduces the concept of ‘quality use of medicines’
and describes the challenges involved in using medicines appropriately. It also provides a
snapshot of how many Australians are at risk of or affected by cardiovascular disease and
summarises the types of medicines available for cardiovascular disease and their indications.
Examples of known gaps between clinical practice and best practice in the use of medicines
to prevent and treat cardiovascular disease are included.
Chapter 3 discusses patterns and trends of community supply and general practice
prescription of cardiovascular medicines for any health problem.
Chapter 4 presents self-reported information on how many Australians use medicines to
manage their cardiovascular conditions and the types of medicines they use.
Chapter 5 shows trends in the prescription of cardiovascular medicines by general
practitioners to manage specific cardiovascular problems and risk factors. There is
information on rates of supply of those medicines to patients by region of residence and
socioeconomic level. Data on whether patients take selected cardiovascular medicines as
intended are also included. This chapter also describes national initiatives to improve the
quality of use of these medicines. Finally it presents information on adverse events
associated with cardiovascular medicines, including deaths and hospitalisations, as well as
initiatives to reduce them.
A detailed breakdown of government expenditure on these medicines, including trends, is
given in Chapter 6.
The Discussion summarises the main findings of the report, draws conclusions from the data
available and identifies gaps and limitations of the existing data.
The classification of medicines, data sources and analytical methods used in this report are
presented in the Appendix. A brief description of the national bodies with responsibility for
quality use of medicines is also included.
Clinical and technical terms are explained in the Glossary.
1
2 Background
Note: the term ‘medicine’ includes prescription, non-prescription and complementary medicines.
Medicines can save lives, help people stay healthy, relieve symptoms of disease, cure some
diseases and improve quality of life. They are a part of most people’s lives. In 1995, almost
six in ten Australians took at least one medicine over a two week period, one in four took
vitamins or minerals and one in ten used herbal remedies (ABS 1999). The use of medicines
increases with age—86% of people aged 65 years and over take medicines, and over 75% of
these take more than one medicine.
Australians spent $10.9 billion on medicines in 2004–05, including $7.1 billion on subsidised
pharmaceuticals and $3.8 billion on other prescription, over-the-counter and complementary
medicines (AIHW 2006b). Expenditure on pharmaceuticals grew by an average 8.9% per
year between 1994–95 and 2004–05, and accounted for 13% of total recurrent health
expenditure in 2004–05.
Medicines also have associated risks. There can be side effects and mistakes made in the
prescribing, administration, dispensing or management of medicines. For the individual, the
risk increases with the number of medicines taken. At the community level, the risk of errors
increases with the volume of medicine use. Medicine problems can be related to over-use,
under-use, misuse or adverse events.
2.1 Quality use of medicines
Australia began developing policies to ensure that essential, affordable medicines of
acceptable quality, safety and efficacy were available as early as the 1950s. By the 1990s a
comprehensive policy was in place and in December 1999 a formal policy document entitled
Australia’s National Medicines Policy was launched, with the following interdependent
objectives:
•
timely access to the medicines that Australians need, at a cost individuals and the
community can afford
•
medicines meeting appropriate standards of quality, safety and efficacy
•
quality use of medicines
•
maintaining a responsible and viable medicines industry (DHAC 1999).
In 2002 the National Strategy for Quality Use of Medicines was put in place as part of the
National Medicines Policy. Quality use of medicines (also known as ‘rational use of
medicines’) means:
•
selecting management options wisely considering the place of medicines in treating
illness and maintaining health, and recognising that there may be better ways to manage
disorders than using medicines
•
choosing suitable medicines if a medicine is considered necessary, taking into account
the individual patient, clinical condition, risks and benefits, dose and length of
treatment, any coexisting conditions, other therapies, monitoring considerations, and
costs for the individual, the community and the health system
2
•
using medicines safely and effectively by monitoring outcomes; minimising misuse,
over-use and under-use; and improving the ability to solve any problems related to
medicines (DoHA 2002).
This definition of quality use of medicines applies equally to decisions about use of
medicines by individuals and by the population as a whole.
National bodies with a key role in promoting and ensuring quality use of medicines are
described briefly in the Appendix.
Performance indicators to monitor the implementation and effect of the National Strategy for
Quality Use of Medicines have been developed (DoHA 2003a). There have been
improvements in the adoption of some practices supporting quality use of medicines, as
measured by these indicators (DoHA 2003b).
2.2 Opportunities and challenges for quality use of
medicines
The management of cardiovascular disease can be regarded as having three phases:
1. Prevention is usually done by general practitioners (GPs) in the community to identify
and help people at risk before disease symptoms appear or a cardiovascular event occurs.
Once a person has been assessed as at risk of cardiovascular disease, doctors may
prescribe medicines, lifestyle changes or both.
2. Treatment during an acute event, such as a heart attack or stroke, typically happens in
hospital.
3. Treatment and ongoing prevention after an acute event occur mainly in the community,
involving GPs, nurses, rehabilitation health professionals and pharmacists.
At each phase there are opportunities and challenges for practising quality use of medicines,
involving multiple stakeholders: health care consumers, carers and the general community;
health practitioners and health educators; health and aged care facilities; medicines industry,
media, health care funders and purchasers; and governments.
Some of the problems that may arise include:
• GPs, nurses and pharmacists unable to keep up to date with evidence for the best
treatment options, especially if a patient is taking several medicines
• GPs lacking skills or resources, which often involve starting patients on a low dose of
medicine and then slowly increasing the dose to therapeutic strength, and monitoring the
medicine’s effects
• specialist physicians focussing on their own disease area, not considering the patient as a
whole with any coexisting health conditions and other medicines they may be taking
• poor communication between doctors and patients, leading to: patients not
understanding the risks, their condition, treatment and desired outcomes; coexisting
health conditions not considered; medicines taken for other health problems and
complementary medicines not discussed and considered; increasing the risk of
interactions and adverse events
• patients unable to take in and remember information on medicines given to them by
health professionals
3
• patients not knowing what medications they are taking and why. This is a problem
particularly for older people who may take several medicines for different coexisting
health conditions and may use a form of dose aid, or where medicine brands are
substituted
• patients refusing to continue treatment as they do not understand that initially doctors
may need to change doses to find a form that is well tolerated and effective
• patients not understanding the importance of monitoring effects of medicines, such as
warfarin and diuretics, putting themselves at risk of drug-adverse events
• patients not taking medicines because they forget to do so, or cannot afford medicines or
visits to the doctor (see also Section 5.2 Concordance with medicines, later in this report)
• patients not taking medicines because they do not understand that their condition is
chronic and has not been ‘cured’; for instance for conditions such as hypertension where
the doctor has told the patient that their blood pressure is controlled. Patients often
misconstrue this as meaning that they can stop taking their medicines.
• patients hoarding medicines when the safety net threshold is reached (see Box 1 in
Chapter 3), or unknowingly keeping expired medicines or empty medicine containers, or
taking medicines prescribed for others
• on admission to hospital, lack of a full list of medicines the patient is taking, which may
result in an adverse event
• at discharge from hospital, inadequate procedures and insufficient information given to
patients and their carers, GPs, nurses and pharmacists to allow adequate follow-up
treatment in the community
• risk of duplication of medicines when provided by more than one source
• poor communication between specialists and GPs and inadequate models of shared care.
According to the National Chronic Disease Strategy, medicine use should be reviewed
regularly, and effective communication and sharing of information between specialist, acute
and primary health care providers, including pharmacists, is essential. Health professionals
also need to be skilled in behavioural interventions, support for self-management and other
evidence-based approaches to encourage people to use medicines optimally (National
Health Priority Council 2006).
A recent international study examined issues of safety, health care coordination, chronic
disease care and access to care and found areas of concern (Schoen et al. 2005). Adults who
had recently been hospitalised, had surgery or had health problems were interviewed in
2005. In Australia, 19% of participants believed they had experienced a medical mistake in
care or were given the wrong medicine or dose, with 63% saying this had happened outside
hospital. Although 92% of Australians surveyed had a regular doctor, a significant
proportion of people with chronic disease reported problems with their doctor:
• clear instructions not given or treatment goals unclear (19%)
• no discussion of treatment choices (45%)
• no review of all medicines taken by patients including those prescribed by other
doctors (46%)
• no explanation of medicine side effects (36%)
• patients not given a plan to self-manage their condition (50%).
4
One in four Australians participating in the survey reported using four or more prescription
medicines regularly and one in five skipped doses or did not fill prescriptions owing to cost.
Among Australians surveyed who had been hospitalised in the previous two years, at
discharge 23% were prescribed new medicines without having their other medicines
reviewed, 18% did not get instructions about symptoms to watch out for, 9% did not know
who to contact with questions about their treatment, and 23% were left without follow-up
care arrangements.
The study’s findings highlight deficiencies in communication between patients and health
professionals, poor care coordination, safety risks and inadequate care of patients with
chronic disease.
2.3 Medicines and cardiovascular disease
Cardiovascular disease affects nearly one in five Australians—about 3.5 million people
(Table 1). Based on self-reports, the most common conditions are hypertension, tachycardia,
coronary heart disease and heart failure. The prevalence of cardiovascular disease increases
with age to 54% in those aged 65 years and over. About 65% of those with cardiovascular
disease report using medicines for their cardiovascular condition(s), amounting to 2.3
million people (ABS 2006). For further details of these medicines, see Chapter 4.
About 20% of people with diabetes also have a long-term cardiovascular condition. Among
those aged 65 years and over, 27% had one or more cardiovascular conditions (ABS 2006).
Diabetes is an important risk factor for cardiovascular disease and cardiovascular conditions,
such as coronary heart disease, stroke and peripheral vascular disease, are important longterm complications of diabetes.
Table 1: Prevalence of selected conditions among Australians, 2004–05
Condition
Hypertension
People with condition
All ages
People with condition
Age 65 years and over
Number (’000)
Per cent
Number (’000)
Per cent
2,100.7
10.5
962.6
37.0
8.1
Tachycardia
417.4
2.1
212.0
Coronary heart disease
366.6
1.8
242.5
9.3
Heart failure and oedema
263.0
1.3
141.0
5.4
Diseases of arteries, arterioles and capillaries
203.6
1.0
120.0
4.6
90.8
0.5
59.6
2.3
All cardiovascular disease
3,536.6
17.6
1,400.2
53.8
High blood cholesterol
1,339.7
6.8
563.4
21.6
3.5
333.2
12.8
Cerebrovascular diseases
Diabetes
699.6
Note: These conditions are explained in the Glossary.
Source: ABS 2006.
Effective medicines to prevent and treat cardiovascular disease are available in Australia.
The recommended indications for medicines used in cardiovascular disease are shown in
Table 2. Note that some of the medicines listed also have other important uses outside the
cardiovascular system, which have been excluded from the table. In this report we use the
5
Anatomical Therapeutic Chemical (ATC) classification of medicines, developed by the World
Health Organisation, because this is the classification adopted by the main data sources
analysed here. The ATC classification is the Australian standard for classifying medicines,
but it does not align well with clinical practice or pharmacology and has confusing
terminology (see also Note on page 9).
Areas needing improvements in clinical practice regarding the use of medicines to prevent
and treat cardiovascular conditions have been identified (National Institute of Clinical
Studies 2003, 2005; Australian Council for Safety and Quality in Health Care and National
Institute of Clinical Studies 2004). Examples include:
•
under-use of antithrombotic (clot-preventing) agents, such as warfarin, to prevent stroke
in patients with atrial fibrillation
•
under-use of Angiotensin-converting-enzyme (ACE) inhibitors and beta-blocking agents
in patients with heart failure
•
under-use of ACE inhibitors and beta-blocking agents in patients with, and following,
acute coronary syndromes
•
under-use of medicines to lower blood pressure in people with hypertension, including
people at high risk of cardiovascular disease
•
under-use of clot-busting medicines (thrombolysis) in eligible patients with stroke.
Table 2: Indications for medicines used in cardiovascular disease
Medicine type (example)
Indications
Comments
Antithrombotic agents
Vitamin K antagonists
(warfarin)
• Prevent and treat venous thromboembolism
• Prevent stroke in patients with atrial fibrillation
• Prevent thromboembolism in patients with
prosthetic heart valves
Heparin group
(enoxaparin)
These medicines have a narrow window
between therapeutic use and toxicity, as
well as many interactions with other
medicines. They require careful
monitoring for safe use.
• Prevent and treat venous thromboembolism in
patients undergoing surgery and high-risk patients
• Treat arterial thromboembolism in acute
myocardial infarction, unstable angina
• Prevent thrombosis during coronary angioplasty,
cardiopulmonary bypass and dialysis
Platelet aggregation
inhibitors
(aspirin)
• Prevent myocardial infarction and stroke in
patients with cardiovascular risk factors
• Prevent myocardial infarction and stroke in
patients with previous myocardial infarction,
stroke, transient ischaemic attack, angina,
peripheral arterial disease or atrial fibrillation
• Treat acute myocardial infarction and acute
ischaemic stroke
• Prevent thrombosis during and after percutaneous
coronary interventions
Thrombolytic enzymes
(alteplase)
• Treat acute myocardial infarction and acute
ischaemic stroke
• Treat peripheral arterial thromboembolism
(continued)
6
Table 2 (continued): Indications for medicines used in cardiovascular disease
Medicine type (example)
Indications
Comments
Cardiac therapy
Cardiac glycosides
(digoxin)
• Treat arrhythmias (atrial fibrillation or flutter)
Antiarrhythmics
(amiodarone)
• Prevent life threatening arrhythmias that could
lead to sudden cardiac death
• Prevent worsening of heart failure
• Treat arrhythmias and relieve symptoms
Cardiac-stimulants
(adrenaline)
• Treat heart arrest
• Treat heart failure
• Treat low blood pressure
• Treat cardiogenic shock due to myocardial
infarction
Vasodilators
(isosorbide
mononitrate)
Antihypertensives
• Prevent and treat angina
• Treat hypertension to prevent disease and deaths
from stroke, coronary heart disease, heart failure
and aortic aneurysm
• Treat hypertension to reduce microvascular
disease affecting kidney, brain and retina
• Agents acting on arteriolar smooth
muscle, such as hydralazine, are
potent blood-pressure-lowering
medicines reserved for refractory
hypertension or for hypertensive
emergencies.
• Centrally acting antiadrenergic agents,
such as methyldopa, are not
recommended as first line treatment as
they are less well tolerated than other
blood-pressure-lowering medicines.
Diuretics
(frusemide)
• Treat hypertension to prevent disease and deaths
from stroke, coronary heart disease, heart failure
and aortic aneurysm
• Treat hypertension to reduce microvascular
disease affecting kidney, brain and retina
Peripheral vasodilators
(oxpentifylline)
Low-dose thiazide diuretics
recommended as first line treatment for
hypertension as they are at least as
effective as all other medicine classes in
lowering blood pressure and are the
least expensive.
• Treat hypertension to prevent disease and deaths
from stroke, coronary heart disease, heart failure
and aortic aneurysm
• Treat hypertension to reduce microvascular
disease affecting kidney, brain and retina
• Treat peripheral vascular disease
Calcium-channel blockers
(amlodipine)
• Treat hypertension to prevent disease and deaths
from stroke, coronary heart disease, heart failure
and aortic aneurysm
• Treat hypertension to reduce microvascular
disease affecting kidney, brain and retina
• Prevent angina
(continued)
7
Table 2 (continued): Indications for medicines used in cardiovascular disease
Medicine type (example)
Beta-blocking agents
(atenolol)
Indications
Comments
• Treat hypertension to prevent disease and deaths
from stroke, coronary heart disease, heart failure
and aortic aneurysm
• Treat hypertension to reduce microvascular
disease affecting kidney, brain and retina
• Treat angina
• Treat arrhythmias
• Prevent further cardiovascular events and death
following myocardial infarction
• Atenolol, metoprolol and propanolol
reduce risk of further cardiovascular
events and death in patients after
myocardial infarction and are
recommended in these patients.
• Used with an ACE inhibitor and a
diuretic, several beta-blockers reduce
risk of death and hospitalisation in
patients with heart failure.
• Treat heart failure
Agents acting on renin–
angiotensin system
• Treat hypertension to prevent disease and deaths
from stroke, coronary heart disease, heart failure
and aortic aneurysm
• Treat hypertension to reduce microvascular
disease affecting kidney, brain and retina
Angiotensinconverting-enzyme
(ACE) inhibitors
(ramipril)
• Treat heart failure and delay disease progression
• Prevent development of heart failure following
myocardial infarction
• Reduce risk of myocardial infarction, stroke and
cardiovascular death in selected patients with
coronary heart disease, stroke, peripheral
vascular disease or diabetes
Recommended first line treatment in
patients with heart failure, or with left
ventricular dysfunction following
myocardial infarction, or with diabetes
and microalbuminuria.
• Diabetic nephropathy
• Prevent worsening of kidney failure
Angiotensin II
antagonists
(irbesartan)
Serum-lipid-reducing
agents
(atorvastatin)
• Treat heart failure and delay disease progression
in patient unable to tolerate ACE inhibitors
• Reduce progression of kidney disease in selected
patients
• Treat lipid disorders to reduce progression of
atherosclerosis and reduce risk of myocardial
infarction and stroke in people with established
cardiovascular disease
• HMG CoA reductase inhibitors (statins)
are the most effective medicines to
reduce LDL cholesterol and are well
tolerated.
• Treat lipid disorders to prevent cardiovascular
disease and deaths in people at high risk of
myocardial infarction and stroke due to the
presence of multiple risk factors
• For raised triglyceride, fibrates are first
choice, but statins may be used instead
if the patient has cardiovascular
disease.
• Nicotinic acid lowers cholesterol and
triglyceride levels, but is often poorly
tolerated.
Notes
1.
Only those indications relevant to cardiovascular disease are listed here. However, some of the medicines in this table have other indications
as well.
2.
Medicines shown in this table are classified according to the Anatomical Therapeutic Chemical (ATC) system. For more information, see the
Appendix.
Source: Australian Medicines Handbook 2006.
8
3 Use of cardiovascular medicines
for any health condition
This chapter presents information on patterns of supply and prescription of cardiovascular
medicines for any health condition in Australia. In this report we have used the medicines
names and groupings of the Anatomical Therapeutic Chemical (ATC) classification of
medicines, described in detail in the Appendix. Medicines used to prevent and treat
cardiovascular conditions belong in the ‘Cardiovascular system’ and the ‘Blood and bloodforming organs’ groups.
Note: throughout this report we have used the term ‘antihypertensives’ strictly to refer to the
group of medicines so labelled in the ATC classification (see Appendix). However, there are
many other medicines used to treat hypertension, which are commonly referred to as
‘antihypertensives’ elsewhere. Here we have referred to all medicines used to treat hypertension
as ‘medicines with blood-pressure-lowering effect’.
3.1 Supply of cardiovascular medicines in the
community
Information on the supply of prescription medicines in the community is available from the
Australian Government Department of Health and Ageing (DoHA). The information is
derived from prescriptions submitted for subsidy payment under the Pharmaceutical
Benefits Scheme (PBS) or the Repatriation Pharmaceutical Benefits Scheme (RPBS) and
estimates of the use of non-subsidised prescription medicines, calculated from data collected
for the Pharmacy Guild of Australia’s ongoing survey of community pharmacies. For more
information on the PBS see Box 1. Data are not available on the use of prescribed medicines
in public hospitals and most private hospitals. Note that as a medicine may have more than
one indication, and the condition for which the medicine is prescribed is not recorded, it is
not possible to determine from these data sources the actual medicine use for specific
conditions or purposes.
Medicine use can be expressed as defined daily dose per 1,000 population per day
(DDD/1,000/day). This is based on the assumed average dose per day of a medicine used
for its main indication in adults. It gives an estimate of how many people per 1,000
population are taking the standard dose of the medicine each day, on average. The DDD
enables valid comparisons between medicines, independent of differences in price,
preparation and quantity per prescription. However, it has several limitations. As the DDD
is based on international experience, it does not necessarily reflect the recommended or
average prescribed dose in Australia. This measure assumes that the amount of medicine
supplied is the same as the amount used, but this is not always the case. Note also that the
DDD is calculated for the whole population, while medicine use may be concentrated in
certain age groups or a particular sex (DoHA 2005).
This section presents information on the community supply of cardiovascular medicines to
manage any health condition (not limited to cardiovascular conditions), as explained above.
9
Box 1: The Pharmaceutical Benefits Scheme
In Australia community prescriptions (that is, not given in public hospitals) are dispensed either as private
prescriptions or under one of two subsidisation schemes—the Pharmaceutical Benefits Scheme (PBS) and
the Repatriation Pharmaceutical Benefits Scheme (RPBS). These schemes were established to provide
Australians with access to necessary medicinal products, which are affordable, available and of acceptable
standards.
A new medicine must gain approval for supply in accord with the requirements of the Therapeutic
Goods Act 1989. Approval is also required to extend the indications of an established medicine.
Applications are dealt with by the Therapeutic Goods Administration (TGA) and, for prescription
medicines, advice is sought from an expert committee, the Australian Drug Evaluation Committee
(ADEC).
Once a prescription medicine is approved for marketing, the company concerned usually applies to have
the medicine listed on the PBS. Because of the attraction of the scheme to consumers, it is usually
necessary for the company to have the medicine listed on the scheme for viable marketing to occur.
The Pharmaceutical Benefits Advisory Committee (PBAC) makes recommendations to the Australian
Government about which medicines should be listed on the PBS. Whereas the pre-market evaluation
examines the issues of quality, safety and efficacy, the PBAC considers effectiveness and cost-effectiveness
of the product compared with other alternatives. Once a medicine has been recommended for listing on the
PBS by the PBAC, the Pharmaceutical Benefits Pricing Authority (PBPA) negotiates the price paid with
the company. The PBPA consists of government, industry and consumer representatives. After agreement
is reached, the Australian Government considers the advice of both the PBAC and the PBPA and makes a
decision on whether the medicine should be listed on the PBS.
Under the PBS, patients are grouped into two classes. General patients pay the first $29.50 of the cost of
each prescription item (called patient co-payment). Pensioner and concessional patients (people with low
incomes and sickness beneficiaries who hold a health care card) pay $4.70 per prescription item.
In addition, there is a safety net to protect people with high medicine needs. Once general patients and/or
their immediate family spend $960.10 on PBS items in a calendar year, prescriptions for the remainder of
that year cost the concessional co-payment amount of $4.70 per item. Once pensioners and concessionals
spend $253.80 on PBS items in a calendar year, they receive all remaining prescriptions free of charge for
the remainder of the year. These co-payments and safety net thresholds are indexed according to the
Consumer Price Index from 1 January each year. The figures quoted here apply for the year 2006.
Patients may also be required to pay a surcharge where the doctor prescribes a more expensive brand of an
item, when there are cheaper, equivalent brands of that item listed on the PBS.
As the general patient co-payment rises, the dispensed price of many of the cheaper medicines falls under
this level. In such cases, the patient pays the full price and no claim for payment is recorded under the
PBS. In 2003, under co-payment general prescriptions represented around 15% of all community
prescriptions. There are also many medicines that are not listed on the PBS or RPBS and are available only
on private prescription with the patient paying the full cost (these represented 7.3% of community
prescriptions in 2003).
The Repatriation Benefits Scheme gives assistance to eligible war veterans and dependants. It is generally
similar to the PBS for concessional beneficiaries.
Sources: DoHA 2005, 2006.
10
In 2003 there were 178.1 million subsidised (PBS/RPBS) prescriptions overall, of which 55.6
million (31.2%) were for ‘cardiovascular system’ medicines and 6.1 million (3.4%) were for
‘blood and blood-forming organs’ medicines (DoHA 2005). In addition, there were an
estimated 42 million prescriptions that did not attract a subsidy, with ‘cardiovascular
system’ medicines accounting for 3.5 million (8.4%) and ‘blood and blood-forming organs’
medicines 0.6 million (1.3%).
Seven ‘cardiovascular system’ medicines were among the top ten most commonly used
medicines by the DDD/1,000/day measure (Table 3). Atorvastatin and simvastatin, both
blood cholesterol-lowering medicines, were the leading medicines using this measure.
Table 3: Top ten medicines by defined daily dose/1,000 population/day, 2005
Rank
Medicine
Action
DDD/1,000/day
1
Atorvastatin*
Lowers blood cholesterol
106.8
2
Simvastatin*
Lowers blood cholesterol
57.5
3
Ramipril*
Lowers blood pressure
38.0
4
Diltiazem hydrochloride*
Lowers blood pressure
30.9
5
Salbutamol
Opens airways
26.2
6
Irbesartan*
Lowers blood pressure
21.9
7
Omeprazole
Lowers gastric acid
20.1
8
Frusemide*
Lowers blood pressure
19.6
9
Aspirin*
Antiplatelet, pain killer, anti-inflammatory
19.3
10
Sertraline
Antidepressant
17.8
Note: * Denotes medicine indicated for cardiovascular disease.
Source: Drug Utilisation Sub-Committee database, DoHA .
Over the period 1995–2005, there were important changes in the supply of medicines for
cardiovascular disease in the community:
• Among medicines with blood-pressure-lowering effect, agents acting on the renin–
angiotensin system were the most popular (121% increase), calcium-channel blockers and
beta-blockers also increased by 21% each, while diuretics fell by 28%, antihypertensives
fell by 37% and peripheral vasodilators, which were dispensed infrequently, fell by 90%
(Figure 1).
• Among serum-lipid-reducing agents, statins rose markedly (1,218% increase). Other types
of medicines in this group were supplied relatively rarely compared with statins
(Figure 2).
• All types of antithrombotic agents increased considerably—platelet aggregation inhibitors
particularly (4,668%), vitamin K antagonists (102%), heparins (846%) (Figure 3).
• Among cardiac therapy medicines, antiarrhythmics rose (49%) while the rest fell—
vasodilators (–7%), cardiac glycosides (–44%) and cardiac-stimulants (–22%) (Figure 4).
Note that for agents acting on the renin–angiotensin system and diuretics, the figures
presented here underestimate their real supply, as DDDs for combination products are not
calculated and are therefore not included in the totals.
11
Compared with other OECD countries for which similar data are available (Table A1),
Australia:
• has a considerably greater use of serum-lipid-reducing agents than any other country on
the list
• is among the top users of agents acting on the renin–angiotensin system and calciumchannel blockers
• is among the countries that uses beta-blocking agents and diuretics the least.
These differences in use of medicines might reflect differences in prevalence of
cardiovascular disease, clinical practices, patients’ preferences, access to medicines and
affordability of medicines in the countries compared, and the rate and level of acceptance of
new evidence.
12
DDD/1,000/day
120
Agents acting on
renin-angiotensin
system
Calcium-channel
blockers
100
80
Diuretics
60
Beta-blocking
agents
40
Antihypertensives
20
Peripheral
vasodilators
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Note: Excludes combinations of agents acting on renin–angiotensin system and diuretics, and combinations of diuretics.
Source: Drug Utilisation Sub-Committee database, DoHA.
Figure 1: Supply of medicines with blood-pressure-lowering effect in the community
DDD/1,000/day
180
Statins
160
Fibrates
140
Bile acid sequestrants
120
Other
100
80
60
40
20
0
1995
1996
1997
1998
1999
2000
2001
2002
Source: Drug Utilisation Sub-Committee database, DoHA.
Figure 2: Supply of serum-lipid-reducing agents in the community
13
2003
2004
2005
DDD/1,000/day
30
Platelet aggregation inhibitors
excluding heparin
25
Vitamin K antagonists
20
Heparin group
15
10
5
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Source: Drug Utilisation Sub-Committee database, DoHA.
Figure 3: Supply of antithrombotic agents in the community
DDD/1,000/day
20
Vasodilators used in
cardiac diseases
15
Cardiac glycosides
10
Antiarrhythmics
5
Cardiac stimulants
excluding cardiac
glycosides
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Source: Drug Utilisation Sub-Committee database, DoHA.
Figure 4: Supply of cardiac therapy medicines in the community
14
2005
3.2 Cardiovascular medicines prescribed in general
practice
This section presents information on cardiovascular medicines prescribed in general practice
for any health problem, sourced from the BEACH study, described in the Appendix. The
BEACH survey of general practice collects information on medicines that GPs prescribe and
advise patients to buy over the counter, and those that GPs supply directly. However, in this
report we have limited the analyses to those medicines prescribed or supplied by GPs.
Box 2: Definitions used in the BEACH study as presented in this report
General practitioner (GP): a medical practitioner who provides primary comprehensive and continuing
care to patients and their families within the community.
Problem: a statement of the GP’s understanding of a health problem presented by a patient.
Encounter: any professional interchange between a patient and a GP.
Medicine: a medicine prescribed or provided by the GP at the encounter.
Medication rate: medicines prescribed or supplied by the GP per 100 problems managed.
In 2004–05, GPs prescribed cardiovascular medicines to manage any health condition at a
rate of 14.7 per 100 encounters, accounting for 17.7% of all general practice prescriptions
(AIHW: Britt et al. 2005). Blood lipid lowering medicines were the most commonly
prescribed cardiovascular medicines (3.0 per 100 encounters), followed by plain ACEinhibitors (2.4 per 100 encounters) and beta-blocking agents (1.7 per 100 encounters).
Comparing the rate at which GPs prescribed or supplied cardiovascular medicines for any
problem in 2000–01 and 2005–06, there were statistically significant changes (p value
<0.0001):
• Among medicines with blood-pressure-lowering effect, agents acting on the renin–
angiotensin system increased, while diuretics fell (Figure 5). Other types of medicines in
this category remained stable.
• Serum-lipid-reducing agents rose, with statins and ‘other cholesterol and triglyceride
reducers’ accounting for the increase (Figure 6).
• Antithrombotic agents increased owing solely to the rise in platelet aggregation inhibitors
such as aspirin (Figure 7).
• Cardiac therapy medicines fell as a result of reduced prescription of cardiac glycosides
and nitrates (Figure 8).
15
Medication rate per 100 problem s
5.0
Agents acting on
renin-angiotensin
system
Calcium-channel
blockers
4.5
4.0
3.5
3.0
2.5
Beta-blocking
agents
2.0
Diuretics
1.5
Antihypertensives
1.0
0.5
Peripheral
vasodilators
0.0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 5: Medicines with blood-pressure-lowering effect prescribed or supplied by GPs
Medication rate per 100 problem s
2.5
2.0
1.5
1.0
0.5
0.0
2000–01
2001–02
2002–03
2003–04
Source: BEACH study (unpublished).
Figure 6: Serum-lipid-reducing agents prescribed or supplied by GPs
16
2004–05
2005–06
Medication rate per 100 problem s
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 7: Antithrombotic agents prescribed or supplied by GPs
Medication rate per 100 problem s
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
2000–01
2001–02
2002–03
2003–04
Source: BEACH study (unpublished).
Figure 8: Cardiac therapy medicines prescribed or supplied by GPs
17
2004–05
2005–06
4 Use of medicines for
cardiovascular disease
The National Health Survey collected self-reported information on medicines used for any
circulatory condition in the two weeks preceding the survey interview. Details of the survey
are given in the Appendix.
Information about medical conditions in the survey is ‘as reported’ by participants—it was
not medically verified and was not necessarily based on diagnosis by a doctor. Some people
with multiple conditions who reported using multiple medicines did not know which
medicine they were taking for each particular condition, so some medicines may have been
incorrectly reported as used for a particular condition, or not reported at all because the
respondent understood it was for a condition not covered in the survey. Therefore, we
should be cautious when interpreting these results.
Note that in the National Health Survey aspirin was included in the category ‘analgesics’—
that is, pain killers—which is one of its effects. However, in the context of cardiovascular
disease, aspirin is more likely to be taken for its antithrombotic effect and elsewhere in this
report aspirin is included in the category ‘antithrombotic agents’.
Overall, 65.2% of people who reported a cardiovascular condition also reported using
medicine for it in the previous two weeks—coronary heart disease 67%, cerebrovascular
diseases 59.3%, and hypertension 88.2% (Table 4).
The most commonly reported medicines for coronary heart disease were vasodilators used
in cardiac disease (37.6%) (that is, cardiac therapy medicines), analgesics (26.4%), and betablockers (25.6%), but a relatively low proportion of people reported taking serum-lipidreducing agents (12.7%).
For cerebrovascular diseases such as stroke, the survey generally does not provide much
useful information on medicines owing to the small number of people with these conditions,
except in the case of analgesics (probably aspirin) reported by 45.3% of people.
Among those who reported diseases of arteries, arterioles and capillaries, 37.3% reported
using analgesics, 23.3% serum-lipid-reducing agents and 18.9% beta-blockers.
For hypertension, the medicines reported most often were agents acting on the renin–
angiotensin system—plain ACE inhibitors (37.3%) and angiotensin II antagonists (31.8%);
and calcium-channel blockers (23.0%).
Additionally, 12.9% of people with a cardiovascular condition reported taking vitamins,
minerals and herbal treatments for it. For coronary heart disease, the proportion was 16.7%
and for hypertension 9.8%.
A person may take more than one medicine simultaneously. People with coronary heart
disease on average reported taking 1.5 cardiovascular medicines for their condition. But the
overall average for all medicines taken by this group for any health condition surveyed was
1.8, including vitamins, minerals and herbal medicines. For people with cerebrovascular
disease, the average number of cardiovascular medicines reported for this condition was 1.4
and the overall average number of medicines reported for any condition surveyed was 1.6.
Those with hypertension reported an average of 1.4 cardiovascular medicines used for this
condition and an average of 1.5 medicines overall for any condition surveyed. Note that the
18
National Health Survey collected information on medicines taken for selected conditions
only, therefore the overall average number of medicines people reported taking may be an
underestimate of their total consumption.
According to a different survey run in South Australia in 2004, which asked about all
prescription medicines taken for any condition, 7.4% of participants aged 15 years and over
used four or five medicines, and 5.7% used six or more (Goldney et al. 2005). The use of
multiple medicines increased with age, so that among people aged 65 years and over, 25.4%
used four or five medicines, and 17.7% used six or more.
Table 4: Medicines used for cardiovascular conditions, 2004–05(a)
Total persons with
cardiovascular condition
Using medicine (%)
Not using medicine (%)
(b)
Total persons using medicine
for cardiovascular condition
Type of medicine used
Cerebrovascular
diseases
Diseases of
arteries,
arterioles and
capillaries
Hypertension
All
cardiovascular
conditions
337,000
90,800
203,600
2,100,700
3,536,600
67.0
59.3
47.6
88.2
65.2
33.0
40.7
52.3
11.6
34.8
225,900
53,800
96,900
1,853,300
2,306,900
Coronary
heart
disease
(c)
Per cent of people using medicine
Vasodilators used in cardiac
diseases
37.6
np
*4.8
0.9
5.1
Low-ceiling diuretics
**0.8
np
np
8.6
8.2
High-ceiling diuretics
*2.2
np
np
*0.5
4.6
Beta-blocking agents
25.6
*12.2
18.9
19.2
23.0
Calcium-channel blockers
13.3
**5.3
*6.5
23.0
21.4
ACE inhibitors, plain
15.3
*14.3
*9.4
37.3
33.6
Angiotensin II antagonists
*3.9
**5.5
*5.1
31.8
27.1
Serum-lipid-reducing agents
12.7
**6.1
23.3
2.8
5.0
Other medicines for heart
and vascular conditions
20.8
49.4
35.7
7.2
15.0
26.4
45.3
37.3
5.8
12.0
9.0
*12.3
**2.6
2.4
5.4
16.7
*7.7
*14.2
9.8
12.9
Analgesics
(d)
All other pharmaceutical
(e)
medicine
Vitamins, minerals and
herbal treatments
(a)
Medicines used for cardiovascular conditions in the 2 weeks before the survey interview, based on self-reports.
(b)
Includes persons for whom use of medicine for cardiovascular conditions was not stated.
(c)
The ABS uses for the National health survey a classification of medicines that is, based on the ATC classification, but differs from it in some
cases. For instance, in the NHS aspirin is classified as an analgesic instead of an antithrombotic agent.
(d)
Includes aspirin.
(e)
Includes medicine reported by respondents as taken for cardiovascular conditions, but are in fact indicated for other conditions.
Notes
1.
Persons may report more than one type of medicine.
2.
Estimates marked with * have a relative standard error (RSE) of between 25% and 50% and should be interpreted with caution.
3.
Estimates marked with ** have a relative standard error (RSE) of more than 50% and are considered to be too unreliable for general use.
4.
np = not available for publication, but included in totals where applicable.
Source: ABS 2006.
19
5 Quality use of cardiovascular
medicines
This chapter presents information on several aspects of the appropriate use of medicines for
cardiovascular disease for which data are available and describes national initiatives aimed
at achieving quality use of these medicines where deficiencies have been identified.
5.1 Medicines prescribed for cardiovascular disease
Data on cardiovascular medicines that GPs prescribed or supplied for specific cardiovascular
conditions and risk factors (hypertension, lipid disorders and diabetes) were sourced from
the BEACH study for the period April 2000–March 2006. For information on this study and
details of the method used to analyse the data, see the Appendix.
Over the period 2000–2006, GPs prescribed or supplied medicines to manage most
cardiovascular problems (Table 5).
Table 5: Medicines prescribed or supplied by GPs for specific problems, 2000–06
Problem managed
Medicine rate per 100 problems (95%CI)
Arrhythmia
81.1 (78.1–84.2)
Diabetes
72.3 (70.5–74.1)
Heart failure
118.6 (114.2–123.0)
Hypertension
96.5 (95.2–97.9)
Ischaemic heart disease
116.6 (113.1–120.1)
Lipid disorder
65.4 (64.4–66.5)
Peripheral vascular disease
37.4 (32.7–42.1)
Stroke
58.7 (53.3–64.1)
Source: BEACH study (unpublished).
Hypertension is the most common problem managed in general practice, at 6.5% of all
problems in 2005–06. Between 2000–01 and 2005–06 the rate of management of hypertension
by GPs increased (from 8.6 to 9.4 hypertension problems managed per 100 encounters). In
2005–06, agents acting on the renin–angiotensin system were by far the most popular
medicines prescribed or supplied for hypertension (53.4 per 100 problems), followed by
calcium-channel blockers (18.9 per 100 problems), beta-blocking agents (11.9 per 100
problems), and diuretics (7.4 per 100 problems), while antihypertensives were seldom
prescribed (1.7 per 100 problems) (Figure 9 and Table e1).
Comparing the rate at which GPs prescribed or supplied cardiovascular medicines for
hypertension in 2000-01 and 2005–06, there were statistically significant changes (p value
<0.0001): agents acting on the renin–angiotensin system increased, while calcium-channel
blockers, diuretics and antihypertensives all fell (Figure 9). Nationwide, these changes
equate to an estimated 220,000 additional occasions each year when GPs prescribed or
supplied agents acting on the renin–angiotensin system for hypertension, and an annual
20
reduction by 40,000 for calcium-channel blockers, 80,000 for diuretics and 10,000 for
antihypertensives. These trends reflect GPs favouring the newer renin–angiotensin system
medicines, which are generally better tolerated than other medicines with blood-pressurelowering effect.
Agents acting on
renin-angiotensin
system
Medication rate per 100 problem s
60
Calcium-channel
blockers
50
Beta-blocking agents
40
Diuretics
30
Antihypertensives
20
Antithrombotic agents
10
Cardiac therapy
0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Serum-lipid-reducing
agents
Source: BEACH study (unpublished).
Figure 9: Medicines prescribed or supplied by GPs in managing hypertension
Lipid disorders represented 2.3% of all problems in general practice in 2005–06, with the rate
of management of these problems by GPs rising between 2000–01 and 2005–06 (from 2.9 to
3.4 lipid disorder problems managed per 100 encounters). GPs prescribed or supplied
serum-lipid-reducing agents in managing lipid disorders at a rate of 68.8 per 100 problems in
2005–06. This rate remained constant over the period 2000–01 to 2005–06 (Figure 10 and
Table e2). This means that the increase in overall prescription of serum-lipid-reducing agents
(see Figure 6) was due to more lipid disorder problems being managed.
Diabetes accounted for 2.4% of all general practice problems in 2005–06. The rate of
management of diabetes by GPs rose between 2000–01 and 2005–06 (from 2.8 to 3.6 diabetes
problems managed per 100 encounters). In 2005–06, GPs prescribed or supplied serum-lipidreducing agents in managing diabetes at a rate of 2.8 per 100 problems and agents acting on
the renin–angiotensin system at 2.5 per 100 problems. There was a statistically significant rise
(p value <0.0001) in the prescription of both these types of medicines to manage diabetes
from 2000–01 to 2005–06 (Figure 11 and Table e3). Nationwide, these changes equate to an
estimated 10,000 additional occasions each year when GPs prescribed or supplied agents
acting on the renin–angiotensin system for diabetes and the same applies to serum-lipidreducing agents.
21
Medication rate per 100 problem s
70
60
50
Serum-lipid-reducing
agents
40
30
20
10
0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 10: Medicines prescribed or supplied by GPs in managing lipid disorders
Medication rate per 100 problem s
Serum-lipid-reducing
agents
3.0
Agents acting on reninangiotensin system
2.5
Calcium-channel
blockers
2.0
Beta-blocking agents
1.5
Antithrombotic agents
1.0
Cardiac therapy
0.5
Diuretics
0.0
Antihypertensives
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 11: Medicines prescribed or supplied by GPs in managing diabetes
22
Ischaemic heart disease represented 0.9% of all problems in general practice in 2005–06, with
the rate of management of such problems remaining constant over the period 2000–01 to
2005–06 (1.3 ischaemic heart disease problems managed per 100 encounters). In 2005–06,
cardiac therapy medicines were the most commonly prescribed or supplied by GPs in
managing ischaemic heart disease (33.1 per 100 problems), followed by beta-blocking agents
(16.2 per 100 problems), serum-lipid-reducing agents (14.5 per 100 problems), agents acting
on the renin–angiotensin system (12.8 per 100 problems), and antithrombotic agents (11.7 per
100 problems) (Figure 12 and Table e4).
Comparing 2005-06 and 2000–01, there were statistically significant differences (p value
<0.0001) in the rate of GP prescription and supply of certain medicines: cardiac therapy and
calcium-channel blockers fell, while antithrombotic agents and serum-lipid-reducing agents
increased (Figure 12). Nationally, these changes amount to an estimated 20,000 additional
occasions each year when GPs prescribed or supplied antithrombotic agents for ischaemic
heart disease and 10,000 extra occasions for serum-lipid-reducing agents. This suggests GPs
are increasingly following recommended guidelines for the treatment of ischaemic heart
disease (Therapeutic Guidelines Ltd 2003). Conversely, cardiac therapy medicines were
prescribed or supplied for ischaemic heart disease at 40,000 less GP encounters each year and
calcium-channel blockers at 10,000 less GP encounters annually.
Medication rate per 100 problem s
Cardiac therapy
50
Beta-blocking agents
40
Serum-lipid-reducing
agents
Agents acting on reninangiotensin system
30
Antithrombotic agents
20
Calcium-channel
blockers
10
Diuretics
Antihypertensives
0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 12: Medicines prescribed or supplied by GPs in managing ischaemic heart disease
23
Heart failure made up 0.4% of all problems managed in general practice in 2005–06. Between
2000–01 and 2005–06 the rate of management of heart failure problems was constant
(0.7 heart failure problems managed per 100 encounters). In 2005–06, GPs prescribed or
supplied mostly diuretics in managing heart failure (50.2 per 100 problems), followed by
agents acting on the renin–angiotensin system (21.9 per 100 problems), beta-blocking agents
(16.5 per 100 problems), and cardiac therapy medicines (12.6 per 100 problems) (Figure 13
and Table e5).
From 2000–01 to 2005–06 there has been a statistically significant increase in the rate at which
GPs prescribed or supplied beta-blocking agents for heart failure (p value <0.0001).
Nationally, this represents 10,000 extra occasions per year on which these medicines were
prescribed or supplied for heart failure. This trend is encouraging in view of the known
under-prescription of beta-blocking agents in people with heart failure but their rate of
prescription is still relatively low.
Medication rate per 100 problem s
Diuretics
60
Agents acting on
renin-angiotensin
system
Beta-blocking agents
50
40
Cardiac therapy
30
Antithrombotic agents
20
Serum-lipid-reducing
agents
10
Calcium-channel
blockers
Antihypertensives
0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 13: Medicines prescribed or supplied by GPs in managing heart failure
Arrhythmias accounted for 0.8% of all general practice problems in 2005–06. The rate of
management of such problems rose over the period 2000–01 to 2005–06 (from 0.8 to 1.1
arrhythmia problems managed per 100 encounters). The medicines that GPs prescribed or
supplied most frequently in managing arrhythmias in 2005–06 were antithrombotic agents
(40.7 per 100 problems), followed by cardiac therapy (17.5 per 100 problems), and betablocking agents (10.3 per 100 problems) (Figure 14 and Table e6). There was a statistically
significant fall (p value <0.0001) in the rate of GP prescription or supply of cardiac therapy
medicines from 2000–01 to 2005–06.
24
Medication rate per 100 problem s
Antithrombotic agents
50
Cardiac therapy
40
Beta-blocking agents
30
Calcium-channel
blockers
Agents acting on
renin-angiotensin
system
Diuretics
20
10
Antihypertensives
0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Serum-lipid-reducing
agents
Source: BEACH study (unpublished).
Figure 14: Medicines prescribed or supplied by GPs in managing arrhythmias
Stroke represented 0.1% of all problems managed in general practice in 2005–06. Between
2000–01 and 2005–06 the rate of management of such problems was relatively constant
(0.2 stroke problems managed per 100 encounters). In 2005–06 the most commonly
prescribed or supplied medicines in managing stroke were antithrombotic agents (21.8 per
100 problems), followed by serum-lipid-reducing agents (5.2 per 100 problems), and agents
acting on the renin–angiotensin system (2.9 per 100 problems) (Figure 15 and Table e7).
There were no statistically significant changes in the rate of GP prescription or supply of any
medicines for stroke in 2005–06 compared with 2000–01. Note that these results are based on
the small number of stroke problems seen in general practice and therefore should be
interpreted with caution.
Peripheral vascular disease accounted for 0.1% of all general practice problems in 2005–06,
with the rate of management of such problems being stable between 2000–01 and 2005–06
(0.1 problems managed per 100 encounters). Antithrombotic agents (4.7 per 100 problems)
and serum-lipid-reducing agents (3.3 per 100 problems) were the medicines GPs prescribed
or supplied most frequently in managing peripheral vascular disease in 2005–06 (Figure 16
and Table e8). There were no statistically significant changes observed in the rate of
prescription or supply of medicines for peripheral vascular disease from 2000–01 to 2005–06.
However, as the number of peripheral vascular disease problems managed by GPs was
small, these results should be regarded with caution.
25
Medication rate per 100 problem s
35
Antithrombotic agents
30
Serum-lipid-reducing
agents
25
Agents acting on reninangiotensin system
Beta-blocking agents
20
Calcium-channel
blockers
15
Cardiac therapy
10
Diuretics
5
Antihypertensives
0
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 15: Medicines prescribed or supplied by GPs in managing stroke
Medication rate per 100 problem s
Antithrombotic agents
12
Serum-lipid-reducing
agents
10
Calcium-channel blockers
Cardiac therapy
8
Diuretics
6
Beta-blocking agents
4
Peripheral vasodilators
2
Agents acting on reninangiotensin system
0
Antihypertensives
2000–01
2001–02
2002–03
2003–04
2004–05
2005–06
Source: BEACH study (unpublished).
Figure 16: Medicines prescribed or supplied by GPs in managing peripheral vascular disease
26
5.2 Concordance with medicines
Medicines can only be effective if patients actually take them. Concordance with medicines
refers to patients using medicines as prescribed, which greatly affects outcomes. For
example, people who do not adhere to their medicine therapy are more likely to have
uncontrolled blood pressure (Chobanian et al. 2003), and have major cardiovascular events
or die (La Rosa et al. 2000, Nelson et al. 2006, Psaty et al. 1990, Rudnicka et al. 2003).
Concordance includes:
• compliance—taking medicines at the prescribed interval and dose (note that sometimes
the term ‘concordance’ is used to refer to compliance)
• persistence—continuing taking medicines for the specified treatment period, which is
usually lifelong in the case of medicines used to prevent cardiovascular disease or reduce
the risk of events such as stroke and heart attack.
This section presents the results of analyses conducted by the Australian Institute of Health
and Welfare of compliance and persistence with selected medicines commonly used to
prevent and treat cardiovascular disease, in newly prescribed patients studied over 2003–06
using data from the Pharmaceutical Benefits Data System supplied by DoHA. Details of the
medicines included, methods used and limitations of the study are given in the Appendix.
HMG COA reductase inhibitors (statins)
Most people dispensed statins in our study were aged 50–79 years, with roughly the same
proportions of males and females (52% versus 48%) and more than half being concessional
patients (Table 6). Statins were supplied to females at a statistically significant lower rate
than for males but the difference was small (411.5 versus 442.4 per 100,000).
People in metropolitan areas were dispensed statins at twice the rate of those living in rural
areas, and 30 times the rate of people in remote areas (Table 7). These differences applied to
both males and females.
Patients were dispensed statins continuously for a period of 422 days on average (Table 8).
At six months from the start of therapy, 83% of patients were persistent with their medicine
(that is, one in six patients had discontinued statins), with this proportion dropping to 65%
after 24 months (Table 8, Figure A1). These figures are comparable to those of previous
studies—56% persistent after 6 months and 50% after 12 months (Benner et al. 2002); 70%
persistent after 6 months (Simons et al. 2000).
The proportion of people who persisted with statins was slightly greater among those living
in rural areas than in metropolitan or remote areas (85% versus 82%) after six months (Table
A2). After 24 months, this pattern remained—68% in rural areas versus 62% in metropolitan
or remote areas.
People in the most socioeconomically disadvantaged group were supplied statins at a higher
rate than those in the least disadvantaged group—for males the difference was 13% and for
females it was 27% (Table A3). The proportion of people who persisted with statins at six
months in the most disadvantaged group was statistically significantly lower than that in the
least disadvantaged group, although the difference was small (Table A4). This difference
remained at 24 months.
In the first 12 months of therapy, 77% of newly prescribed patients were assessed as
compliant with statins, that is, they had sufficient medicine to use it at the prescribed
frequency and dose.
27
Agents acting on the renin–angiotensin system
For this group of medicines, analyses were limited to concessional and RPBS patients. Those
supplied angiotensin II antagonists (plain or combinations) or ACE inhibitors (plain or
combinations) in the study were mostly aged 60 years or over, and women represented a
larger proportion than men (Table 6). Females were supplied angiotensin II antagonists at a
rate 1.5 times that for males. Supply of ACE inhibitors combinations among females was 1.3
times the rate for males, but the difference was not as marked for plain ACE inhibitors.
People in metropolitan areas were dispensed angiotensin II antagonists at nearly twice the
rate of those living in rural areas, and 47–58 times the rate of people in remote areas (Table
7). Supply of ACE inhibitors to people in metropolitan areas was 1.7 times the rate of their
counterparts living in rural areas, and 29–36 times the rate in remote areas. These differences
were present in both males and females.
On average, patients were continuously supplied with these medicines for a period ranging
from 432 days for angiotensin II antagonists combinations to 364 days for ACE inhibitors
combinations (Table 8). At six months from commencing medicine treatment, 88–91% of
patients persisted with their treatment and after 24 months 75–79% were still taking the
medicines, depending on the medicine studied (Table 8, Figure A2). International studies
have reported similar results—after 12 months 71% persistent with plain ACE inhibitors,
73% with plain angiotensin II antagonists and 67% with medicine combinations, dropping to
58%, 59% and 50% respectively after 36 months (Perreault et al. 2005); 66% persistent with
angiotensin II antagonists at 12 months and 56% at 24 months, 59% persistent with ACE
inhibitors at 12 months and 47% at 24 months (Bourgault et al. 2005).
The proportion of people persistent with angiotensin II antagonists at six months was
slightly greater in rural areas than in metropolitan areas (Table A2). This difference remained
after 24 months. For ACE inhibitors, persistence was greatest among patients living in rural
areas and lowest in remote areas after six and 24 months.
In the first 12 months of therapy, 87% of newly prescribed patients were assessed as
compliant with ACE inhibitors or plain angiotensin II antagonists, and 89% were compliant
with angiotensin II antagonists combinations.
Beta-blocking agents
Only concessional and RPBS patients were included in the study of beta-blockers. People
dispensed beta-blocking agents were mainly aged 60 years and over, with similar
representation of females and males (52% versus 48%) (Table 6). Females were supplied betablockers at a slightly higher rate than males (165.0 versus 149.4 per 100,000).
People in metropolitan areas were dispensed beta-blocking agents at 1.6 times the rate of
those living in rural areas, and 31–37 times the rate of people in remote areas (Table 7). These
differences applied to both males and females.
The average duration of persistence with beta-blocker treatment was 329 days (Table 8). At
six months from the start of therapy, 75% of patients continued filling their prescriptions,
falling to 53% at 24 months. International studies have shown comparable results—50%
persistent at 12 months and 39% at 24 months (Bourgault et al. 2005); 68% persistent at 12
months and 57% at 36 months (Perreault et al. 2005).
Persistence with beta-blocking agents was slightly greater in rural areas compared with
metropolitan areas (77% versus 74%) at six months (Table A2). We observed the same
difference after 24 months (55% versus 51%).
28
Note that in some cases patients are prescribed beta-blocking agents for a limited period and
we did not have access to information to identify and exclude those patients from our
analysis. Therefore, this may partly account for the large discontinuation rate we found.
Warfarin
Analysis of warfarin supply was limited to concessional and RPBS patients. Most people
supplied warfarin were aged 60 years and over, with males and females equally represented
(Table 6). There was no difference between males and females in the rate of supply of
warfarin.
Males in metropolitan areas were dispensed warfarin at 1.6 times the rate of those living in
rural areas, and 36 times the rate of people in remote areas (Table 7). For females, those
living in metropolitan areas had 1.9 times the rate of supply of their rural area counterparts
and 48 times that of women in remote areas.
On average, patients were dispensed warfarin continuously for a period of 288 days
(Table 8). At six months from commencement of therapy, 84% of patients persisted with
treatment and by 24 months 57% were still taking the medicine (Table 8, Figure A3). An
earlier study showed 85% persistence at 3 months and 77% at 12 months (Hamann et al.
2003).
There was very little difference in the proportion of patients who continued using warfarin
in metropolitan, rural or remote areas (Table A2).
Note that in some cases patients are prescribed warfarin for a limited period and we did not
have access to information to identify and exclude those patients from our analysis. Hence
this may explain part of the large discontinuation rate observed at 24 months.
Other antithrombotic agents
Note that we excluded aspirin from the analysis because it is widely available over-thecounter and this supply is not recorded in the Pharmaceutical Benefits Data System. In
addition, aspirin is indicated for other conditions outside the cardiovascular system.
In our study, the group ‘other antithrombotic agents’ included clopidogrel, dipyridamole
and ticlopidine. People dispensed these medicines were mostly aged 60 years and over, with
a higher proportion of males than females (59% versus 41%) (Table 6). Males were supplied
these antithrombotic medicines at a rate 1.4 times that of females.
People in metropolitan areas were dispensed these antithrombotic agents at twice the rate of
those living in rural areas, and 41–47 times the rate of people in remote areas (Table 7). These
differences applied to both males and females.
Patients were continuously supplied these antithrombotic agents for a period of 391 days on
average (Table 8). After six months of therapy, 90% of patients persisted with these
medicines and this proportion fell to 76% after 24 months (Table 8, Figure A3). Previously
reported figures are 82% of patients persistent with clopidogrel therapy at 3 months and 62%
at 12 months (Hamann et al. 2003).
There was no difference in persistence with these antithrombotic agents in people living in
metropolitan, rural or remote areas (Table A2).
People in the most socioeconomically disadvantaged group were supplied these
antithrombotic agents at a higher rate than those in the least disadvantaged group—for
males the increase was 5% and for females it was 8% (Table A3). The level of persistence
with these medicines was similar in all socioeconomic groups (Table A4).
29
In the first 12 months of therapy, 90% of newly prescribed patients were assessed as
compliant with these antithrombotic agents. This means they had enough medicine to take it
at the prescribed frequency and dose.
30
(c)
(b)
Includes repatriation patients and repatriation patients on safety net.
(d)
7.2
66.6
26.2
125.7
(124.9–126.5)
87.4
(86.7–88.1)
59.3
40.7
21.1
30.1
24.6
16.5
6.2
1.5
155,445
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
31
Age group and category of patients were determined at the time of their first prescription being dispensed.
10.5
89.5
0.0
64.1
(63.5–64.7)
64.2
(63.7–64.8)
50.4
49.6
22.5
37.1
24.1
8.0
3.8
4.4
93,120
Warfarin
Other
antithrombotic
(a)
agents
3.
8.0
92.0
0.0
149.4
(148.5–150.3)
165.0
(164.0–165.9)
47.9
52.1
18.8
30.0
27.3
12.7
6.3
5.0
228,221
Beta-blocking
agents
Rate per 100,000 population, age standardised to the Australian population at 30 June 2001.
6.8
93.2
0.0
27.8
(27.4–28.2)
37.9
(37.5–38.4)
42.6
57.4
15.1
31.9
30.2
13.6
6.3
2.9
47,624
ACE inhibitors
(combinations)
The study included newly prescribed patients only. For ‘statins’ and ‘other antithrombotic agents’ patients in all categories were included. For all other medicine groups, the analysis was limited to concessional patients and RPBS patients.
8.4
91.6
0.0
211.1
(210.0–212.1)
234.2
(233.1–235.3)
47.7
52.3
20.4
31.1
27.0
12.1
6.0
3.3
323,545
ACE inhibitors
(plain)
2.
6.5
93.5
0.0
55.2
(54.6–55.7)
86.6
(85.9–87.3)
39.2
60.8
14.0
33.5
31.9
12.9
5.4
2.2
102,624
Angiotensin II
antagonists
(combinations)
Medicine class
1.
Notes
Includes general ordinary patients and general patients on safety net.
Includes concessional ordinary patients and concessional patients on safety net.
(c)
7.7
92.3
0.0
142.7
(141.8–143.6)
209.5
(208.4–210.5)
40.8
59.2
16.9
33.4
29.5
12.1
5.6
2.6
255,177
Angiotensin II
antagonists (plain)
(b)
Includes clopidogrel, dipyridamole and ticlopidine.
4.2
54.2
(a)
RPBS (%)
(d)
Concessional (%)
General (%)
41.6
442.4
(440.9–443.9)
Males (rate)
[95% CI]
Patient category
411.5
(410.0–413.0)
Females (rate)
[95% CI]
51.8
Males (%)
18.0
70–79 (%)
48.2
25.6
60–69 (%)
Females (%)
28.7
50–59 (%)
7.6
14.7
40–49 (%)
80+ (%)
5.5
619,815
0–39 (%)
Age group
Number
HMG COA
reductase
inhibitors (statins)
Table 6: Characteristics of the patients studied
0.86 (0.79–0.93)
21.91 (21.57–22.24)
41.46 (40.98–41.93)
1.06 (0.99–1.14)
24.29 (23.94–24.65)
38.69 (38.24–39.14)
Warfarin
1.24 (1.16–1.32)
28.16 (27.78–28.55)
57.97 (57.42–58.53)
1.99 (1.89–2.09)
41.29 (40.83–41.75)
82.42 (81.76–83.07)
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
32
Region of residence of patients was determined at the time of their first prescription being dispensed.
2.72 (2.61–2.84)
61.48 (60.91–62.05)
100.63 (99.89–101.36)
2.93 (2.80–3.05)
57.69 (57.15–58.24)
88.71 (88.03–89.39)
Beta-blocking agents
Other
antithrombotic
(a)
agents
3.
0.71 (0.65–0.77)
13.43 (13.16–13.69)
23.78 (23.42–24.14)
0.54 (0.48–0.59)
10.13 (9.90–10.36)
17.10 (16.80–17.40)
ACE inhibitors
(combinations)
Rate per 100,000 population, age standardised to the Australian population at 30 June 2001.
4.22 (4.07–4.37)
85.38 (84.72–86.05)
144.43 (143.56–145.30)
4.35 (4.19–4.49)
81.59 (80.94–82.23)
125.03 (124.22–125.84)
Rate (95% CI)
ACE inhibitors
(plain)
The study included newly prescribed patients only. For ‘statins’ and ‘other antithrombotic agents’ patients in all categories were included. For all other medicine groups, the analysis was limited to concessional patients and RPBS patients.
0.99 (0.92–1.06)
28.27 (27.88–28.65)
57.38 (56.82–57.93)
0.71 (0.65–0.77)
18.30 (17.99–18.61)
36.19 (35.75–36.63)
Angiotensin II
antagonists
(combinations)
2.
Includes clopidogrel, dipyridamole and ticlopidine.
2.49 (2.39–2.61)
72.11 (71.49–72.72)
134.85 (134.00–135.69)
1.93 (1.83–2.03)
51.41 (50.89–51.92)
89.38 (88.69–90.07)
Angiotensin II
antagonists (plain)
Medicine class
1.
Notes
(a)
7.57 (7.37–7.76)
136.32 (135.48–137.15)
Rural
Remote
267.56 (266.38–268.75)
Metropolitan
Females
9.55 (9.32–9.77)
147.24 (146.37–148.11)
Rural
Remote
285.61 (284.39–286.83)
HMG COA reductase
inhibitors (statins)
Metropolitan
Males
Region of
residence
Table 7: Prescriptions supplied by region of patient residence
102,624
323,545
Angiotensin II antagonists (combinations)
ACE inhibitors (plain)
Includes clopidogrel, dipyridamole and ticlopidine.
(a)
155,445
93,120
228,221
391
288
329
364
369
432
393
422
Days
Average duration
of persistence
90.02 (89.86–90.18)
83.75 (83.49–84.01)
75.15 (74.96–75.34)
90.62 (90.33–90.90)
88.38 (88.26–88.50)
90.86 (90.67–91.05)
88.79 (88.66–88.92)
83.44 (83.34–83.54)
6 months
83.87 (83.65–84.08)
71.94 (71.57–72.31)
63.66 (63.43–63.89)
85.43 (85.05–85.80)
82.13 (81.97–82.29)
85.86 (85.62–86.10)
82.38 (82.21–82.55)
74.65 (74.53–74.77)
18 months
79.42 (79.16–79.68)
63.23 (62.78–63.68)
57.26 (57.01–57.51)
81.65 (81.19–82.10)
77.99 (77.81–78.17)
81.95 (81.66–82.23)
78.13 (77.93–78.33)
68.97 (68.83–69.11)
Per cent (95%CI)
12 months
Proportion of patients persistent at:
76.08 (75.78–76.37)
56.60 (56.08–57.11)
52.89 (52.62–53.16)
78.82 (78.29–79.34)
74.81 (74.60–75.02)
79.19 (78.86–79.51)
74.89 (74.66–75.12)
64.92 (64.77–65.07)
24 months
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
33
Note: The study included newly prescribed patients only. For ‘statins’ and ‘other antithrombotic agents’ patients in all categories were included. For all other medicine groups, the analysis was limited to concessional patients and
RPBS patients.
(a)
Other antithrombotic agents
Warfarin
Beta-blocking agents
47,624
255,177
Angiotensin II antagonists (plain)
ACE inhibitors (combinations)
619,815
Number of patients
HMG COA reductase inhibitors (statins)
Medicine class
Table 8: Persistence with medicines
As stated earlier, the medicines included in this study of concordance were selected because
they are usually indicated for lifelong use in the prevention and treatment of cardiovascular
disease. However, we observed that a considerable proportion of newly prescribed patients
were dispensed one script only for these types of medicines, ranging from 14% to 27% (Table
9). Assuming patients were dispensed the cheapest PBS item in the relevant medicine class,
this equates to a minimum cost to government and patients of
$7.4 million. It is likely that this early discontinuation of medication is due to side effects that
occur in the first month of therapy. Although the rates of side effects with many of these
medicines are low in clinical trials, patients in the real world may attribute side effects to
medicines more commonly and stop taking them.
Table 9: Newly prescribed patients dispensed one prescription only
Newly prescribed patients dispensed
one script only
(number)
% of total newly
prescribed patients
Minimum cost for
patients
dispensed one
(a)
script only ($)
393,879
105,460
26.8
834,189
61,701
11,462
18.6
265,918
416,001
69,619
16.7
960,742
116,698
18,497
15.9
143,907
197,389
31,093
15.8
1,016,741
Angiotensin II antagonists
(combinations)
127,190
18,962
14.9
414,130
Angiotensin II antagonists
(plain)
317,389
46,862
14.8
908,186
HMG COA reductase
inhibitors (statins)
792,338
110,022
13.9
2,857,271
Total newly
prescribed patients
(number)
Medicine class
Beta-blocking agents
ACE inhibitors (combinations)
ACE inhibitors (plain)
Warfarin
Other antithrombotic agents
(b)
Total
7,401,084
(a)
Assumes that patients who filled one script only were dispensed the cheapest preparation in the relevant medicine class available on the
Pharmaceutical Benefits Scheme in 2006. Calculations used 2006 prices.
(b)
Includes clopidogrel, dipyridamole and ticlopidine.
Note: For ‘statins’ and ‘other antithrombotic agents’ patients in all categories were included. For all other medicine groups, the analysis was
limited to concessional patients and RPBS patients.
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
Overall, the results of our study indicate a high level of discontinuation of medicines that are
generally intended to be taken long-term. This represents a significant waste of resources
and a lost opportunity to prevent cardiovascular disease with medicines known to be
effective. Note that due to the limitations of the data set, discontinuation rates may have
been over-estimated to some extent (see Methods section in the Appendix for details).
Previous research has shown that, across a wide range of medical disorders, about 75% of
medicines are taken as prescribed, and that compliance decreases as the number of daily
doses increases (Cramer 2002, Claxton et al. 2001).
Factors associated with poor concordance with medicines include:
• treatment of a condition with no symptoms (such as high blood pressure and high blood
cholesterol)
• presence of depression
• inadequate follow-up or discharge planning
34
• side effects of medicine
• poor communication between health professional and patient
• patient’s lack of understanding of their condition
• patient’s lack of belief in the benefit of treatment
• complexity of treatment
• missing doctor’s appointments and
• cost of medicines (Osterberg et al. 2005, WHO 2003).
We do not have access to patient information that would allow us to explore the reasons for
discontinuing medicine treatment in our study. The fact that for the most part our analyses
were confined to concessional patients, for whom out-of-pocket expenses on medicines
would be relatively low, suggests that cost does not play a big role. However, research
indicates that one in five sicker Australians omits a medicine owing to cost (Schoen et al.
2005).
According to international studies, people with a history of coronary heart disease, stroke,
heart failure, diabetes or hypertension are more likely to keep taking lipid-lowering and
blood-pressure-lowering medicines than those without these conditions (Benner et al. 2002,
Chapman et al. 2005). As patients’ medical histories are not recorded in national databases in
Australia, we were unable to look into this issue in our analyses.
5.3 National Prescribing Service initiatives
The National Prescribing Service (NPS) conducts a range of initiatives to promote quality use
of medicines (National Prescribing Service 2004, 2005). For more information on the NPS, see
the Appendix. Among NPS activities relating to cardiovascular disease medicines are:
•
education and quality assurance programs for health professionals using a range of
publications and interventions, including clinical audits, education visiting, peer group
discussions and case studies. Over the period 1999–2004, a considerable proportion of
GPs has participated in such a program covering hypertension (52%), lipid disorders
(37%), heart failure (15%), antithrombotics (6%), as well as multiple medicine use (7%)
and medicine reviews (8%). Note that these figures cannot be added together as GPs
may have participated in more than one program activity.
•
publications for health professionals on newly listed or revised cardiovascular
medicines.
•
telephone advice line for health professionals (Therapeutic Advice and Information
Service) and for consumers (Medicines Line), where cardiovascular medicines are a
frequent topic. Calls relate mostly to medicine interactions and adverse drug reactions.
•
information material for consumers on self-management of heart failure
•
information program for consumers to encourage older people to be more active in
managing their medicines
•
Medicines List to help consumers who take multiple medicines keep track of their
medicines.
Clinical audits provide an opportunity for GPs to reflect on their prescribing practice. Onefifth of Australian GPs had reviewed their management of hypertension through NPS
35
clinical audits between 1999 and 2004. For management of lipid disorders, the corresponding
proportion was one-tenth.
A NPS study involved 5,247 GPs who voluntarily participated in one of four clinical audits
on hypertension held in 1999, 2001, 2003 and 2004, and provided self-reported data for
105,086 adult patients with a history of hypertension (National Prescribing Service,
unpublished). The objectives of the audits were to review management of hypertension
against guidelines, identify ideal target blood pressure for individual patients and optimise
blood pressure control, and review the selection of antihypertensive medicine.
Note that as GPs participating in the clinical audits were self-selected and the data were selfreported, the sample of GPs or their patients may not represent the whole of Australia and
therefore these results may not be generalised and we should be cautious when interpreting
them. For some measures, the survey questions changed over time and direct year-to-year
comparisons are not entirely appropriate, but the results give an indication of the trends.
Results showed that management of hypertension in general practice had improved between
1999 and 2004. Target blood pressures were likely to be consistent with guideline
recommendations and more patients were achieving control of their blood pressure—70% in
2004. The proportion of patients using one blood-pressure-lowering medicine fell from 52%
in 1999 to 45% in 2004, in favour of combinations of medicines (data not shown).
The most commonly prescribed agents with blood-pressure-lowering effect were ACE
inhibitors, calcium-channel blockers and beta-blockers (Table 10). The increasing use of
combination products resulted in increasing overall use of low-dose thiazide diuretics, ACE
inhibitors and angiotensin II antagonists.
Table 10: Medicines with blood-pressure-lowering effect prescribed
Type of antihypertensive medicine
prescribed
1999
2001
2003
2004
Per cent of patients
Low-dose thiazide diuretics
14
11
10
10
High-dose thiazide diuretics
7
7
5
4
Beta-blocking agents
24
24
24
24
Calcium-channel blockers
37
33
33
31
ACE inhibitors
46
41
36
36
Low-dose thiazide and ACE inhibitor
combination
n/a
6
9
10
Angiotensin II antagonists
13
17
20
22
Low-dose thiazide and angiotensin II
antagonist combination
n/a
8
13
14
4
3
3
3
12
6
4
5
Alpha-blocking agents
Other antihypertensive medicines
Source: National Prescribing Service, unpublished.
In accordance with guidelines (Therapeutic Guidelines Ltd 2003), there was an increase in
patients using a blood-pressure-lowering medicine most suited to their coexisting health
conditions (58% in 1999 versus 81% in 2004). However, the proportion of patients with
coexisting heart failure prescribed ACE inhibitors was low at 54–62% (Table 11). Similarly,
fewer than 52% of patients with a history of myocardial infarction were prescribed betablockers or ACE inhibitors. GPs reported simultaneous use of medicines known to
36
exacerbate hypertension in 24% of patients in 2001, 19% in 2003 and 17% in 2004.
Complementary medicines that could raise blood pressure were reported in 1–2% of patients
with hypertension.
Table 11: Patients with hypertension and a coexisting condition prescribed blood-pressurelowering medicines with favourable or unfavourable effects on coexisting conditions
Coexisting condition
Medicines with effect on coexisting condition
2001
2003
2004
Favourable effect
Per cent of patients
ACE inhibitor
58
62
54
Beta-blocking agent
26
35
32
Microalbuminuria/proteinuria
ACE inhibitor or angiotensin II antagonist
n/a
39
45
Previous myocardial infarction
Beta-blocking agent
49
45
49
ACE inhibitor
52
50
51
Beta-blocking agent plus ACE inhibitor
23
23
26
Beta-blocking agent or calcium-channel blocker
76
64
45
Heart failure
Angina
Unfavourable effect
Bradycardia
Beta-blocking agent
22
23
21
Bilateral renal stenosis
ACE inhibitor or angiotensin II antagonist
41
54
32
Source: National Prescribing Service, unpublished.
5.4 National Institute of Clinical Studies initiatives
The National Institute of Clinical Studies (NICS) has initiated a range of activities to improve
clinical practice in Australia. For more information on NICS, see the Appendix. Two NICS
initiatives relating to cardiovascular disease medicines are described here.
Reducing time to thrombolysis
Forty-seven hospitals came together in 2002 to form a national emergency department
collaborative whose aim was to develop and implement programs that would reduce
waiting times for treatment, including time to thrombolysis (National Institute of Clinical
Studies 2004a). There is overwhelming evidence that early thrombolysis (treatment with clotbusting medicines) leads to less morbidity and deaths in patients with myocardial infarction.
While patients get benefit from treatment up to 12 hours after the onset of symptoms, the
beneficial effect is substantially higher if patients are treated within 90 minutes of the onset
of symptoms.
The Australian national benchmark for time from assessment in the emergency department
to start of thrombolysis (‘door-to-needle’ time) is 30 minutes. In South Australia three
emergency departments participated in the collaborative, resulting in their average time to
thrombolysis dropping from 58 minutes to 44 minutes, with 75% of patients receiving
thrombolysis within 30 minutes after the collaborative, compared with 16% previously. Each
organisation used different models and developed processes that suited them to achieve
these improvements.
37
Heart failure
NICS developed a program to improve the quality of care for people with heart failure,
which had been identified as an area with major gaps between actual clinical practice and
best practice (National Institute of Clinical Studies 2004b). It is a collaboration with the
National Prescribing Service, National Heart Foundation of Australia and Divisions of
General Practice.
As part of the program, NICS conducted a study to identify barriers to managing heart
failure in general practice (Phillips et al. 2004). Concerns about possible side effects of the
medicines and lack of awareness of their effectiveness were common reasons for suboptimal
use of ACE inhibitors. Under-use of beta-blocking agents was due mainly to concerns about
side effects, contraindications and coexisting conditions, being unaware of their value and
lack of experience initiating treatment with these medicines.
Among other objectives, the program encourages doctors to prescribe appropriate medicines
at optimal doses, particularly ACE inhibitors and beta-blocking agents, through a range of
interventions. Evaluation results of the program will be available in 2007.
5.5 National Primary Care Collaboratives
The Australian Primary Care Collaboratives program, an initiative of the Australian
Government Department of Health and Ageing, aims to improve clinical health outcomes,
reduce lifestyle risk factors and maintain good health in people with chronic and complex
conditions. Its initial focus is on promoting quality improvement in primary health care in
the prevention, management and underpinning clinical and business systems relating to
cardiovascular disease and diabetes. Program activities started in February 2005 (National
Primary Care Collaboratives 2006).
Results to date for participating practices show marked improvements in the:
• proportion of patients with coronary heart disease taking aspirin
• proportion of patients with coronary heart disease taking a statin (cholesterol-lowering
agent)
• proportion of patients who had a myocardial infarction in previous year taking betablocking agents
• proportion of patients with coronary heart disease with blood pressure below 140/90 mm
Hg (Table 12).
38
Table 12: Quality practices in management of coronary heart disease among participants in
Australian primary care collaboratives
Group 1
Indicator
At start
Group 2
After 17
months
At start
After 9
months
Per cent
Patients with coronary heart disease taking
aspirin
43
66
54
62
Patients with coronary heart disease taking a
statin
41
73
62
71
Patients who had a myocardial infarction in
previous year taking beta-blocking agents
29
63
41
64
Patients with coronary heart disease with blood
pressure below 140/90 mm Hg
36
51
30
48
Notes
1.
157 general practices participated in Group 1 and 159 in Group 2 nationally. The mean of the results from all participating practices is shown.
2.
Results shown here are current at the time of preparing this report but the collaboratives are continuing so more recent information will be
available in future.
Source: National Primary Care Collaboratives 2006.
5.6 Section 100 initiative
Despite Indigenous Australians having poorer health than other Australians, expenditure on
PBS medicines among Indigenous people was one-third that for other Australians in 2001–02
(AIHW 2005). The supply of PBS medicines to remote area Aboriginal and Torres Strait
Islander Health Services under Section 100 of the National Health Act of 1953 is an initiative
introduced in 1999 to improve access to PBS medicines for Indigenous people.
Under these arrangements, patients attending approved remote area Aboriginal and Torres
Strait Islander Health Services are able to get medicines from an on-site dispensary at the
health service, without the need for a prescription form and without charge.
In 2001–02 the Australian Government spent $35.9 million on all medicines for Indigenous
people, including $10.9 million on PBS medicines supplied under Section 100 arrangements
to remote area Aboriginal and Torres Strait Islander Health Services, compared with $4,671.4
million and $1.2 million for non-Indigenous people respectively (AIHW 2005).
The Section 100 arrangements benefit 36% of the Aboriginal and Torres Strait Islander
population and have resulted in an increase of $36.4 million expenditure on PBS medicines
for Indigenous people from 2000–01 to 2002–03 associated with, for example, increased
access to ACE inhibitors (Kelaher et al. 2004).
5.7 Drug-adverse events
Drug-adverse events are medicine problems that result in harm to the patient. They may
arise from over-use and under-use of medicines, as well as from reactions to medicines and
interactions between medicines. Although there may be a low likelihood of individual drugadverse events occurring, the large numbers of people taking medicines increase the
potential for events and presents a major problem. The risk is higher for people taking
39
multiple medicines, particularly older people. It has been estimated that 2–3% of all
unplanned hospitalisations in Australia are related to medicines, rising to about 20% among
people aged over 65 years (Australian Council for Safety and Quality in Health Care 2002).
Medicines for heart disease and hypertension and anticoagulants are among the most
commonly involved indrug-adverse events.
According to a survey run in South Australia, 52% of respondents used complementary
medicines in 2004, 50% had used conventional medicines on the same day, and 53% did not
report the use of complementary medicines to their doctor (MacLennan et al. 2006). It is not
unusual for younger women to give complementary medicines to older relatives with
chronic diseases without first checking safety of interactions with conventional medicines
(Gowan 2006).
One in ten patients presenting to a GP has had a medicine incident in the preceding six
months, defined as an ‘unintended event due to the use of medicine that could have harmed
or did harm the patient’ (Miller et al. 2006). About 8% of these patients were hospitalised as a
result and GPs thought 23% of all medicine incidents could have been prevented. The most
common reason given for a medicine incident was a recognised medicine side effect (72%),
followed by medicine sensitivity (12%) and allergy (11%).
Factors that may lead to drug adverse events in hospital include omission of therapy,
overdose, administration of the wrong medicine, failure to read or misreading the patient
chart, prescription errors, and dispensing errors in hospital pharmacies. In general practice,
there may be communication problems, inadequate review of patient history, lack of
protocols, or errors in assessment leading to the use of an inappropriate medicine or dose,
prescribing errors and administration errors. Problems with medicines may also arise from
lack of communication in the transition between hospital and community care, and when
patients consult several health care providers who may not know the patient’s full medical
history and medicines they are taking (Australian Council for Safety and Quality in Health
Care 2002).
Information on deaths and hospitalisations associated with drug-adverse effects is available
from the National Mortality Database and the National Hospital Morbidity Database,
respectively. The data shown here refer to the ICD-10 and ICD-10-AM codes defined as
‘drugs, medicaments and biological substances causing adverse effects in therapeutic use’
and are limited to those medicines that are relevant to cardiovascular disease. This category
includes correct medicine properly administered in a therapeutic or prophylactic dose as the
cause of any adverse effect. It excludes accidents in the technique of administration of
medicines, accidental overdoses of medicines, wrong medicines given or taken in error, and
medicines taken inadvertently.
In 2004 there were 301 deaths with adverse effects of medicines that may be used to prevent
or treat cardiovascular disease recorded (Table 13). Drug-adverse effects were the underlying
cause in 29 deaths (9.6%) and an associated cause in 272 deaths (90.4%), indicating that for
most of these deaths the drug-adverse effect was not considered the main cause of death.
Anticoagulants were the medicines most commonly reported as causes of death.
40
Table 13: Deaths with adverse effects of medicines used to prevent or treat cardiovascular disease,
2004
Underlying
cause deaths
Associated
cause deaths
Total
deaths
19
211
230
Anticoagulant antagonists, vitamin K and other coagulants (Y44.3)
0
21
21
Thrombolytic drugs (Y44.5)
0
10
10
Salicylates (Y45.1)
4
10
14
β-Adrenoreceptor antagonists, not elsewhere classified (Y51.7)
1
1
2
Cardiac-stimulant glycosides and drugs of similar action (Y52.0)
0
5
5
Other antidysrhythmic drugs, not elsewhere classified (Y52.2)
4
9
13
Angiotensin-converting-enzyme inhibitors (Y52.4)
1
1
2
Antihyperlipidaemic and antiarteriosclerotic drugs (Y52.6)
0
2
2
Loop (high-ceiling) diuretics (Y54.4)
0
1
1
Other diuretics (Y54.5)
0
1
1
29
272
301
Medicine class (ICD-10 code)
Anticoagulants (Y44.2)
Total
Notes
1.
Some of the medicines listed in this table are used to treat a range of conditions outside the cardiovascular system. The particular
condition for which the medicine was indicated is not recorded.
2.
Underlying cause of death is the disease or injury initiating the sequence of events leading to death, that is, the main cause.
3.
Associated cause of death is any disease or injury, other than the underlying cause of death, contributing to death.
Source: AIHW National Mortality Database.
There were 28,449 hospital separations with codes for adverse effects of medicines that may
be used to treat or prevent cardiovascular disease recorded in 2004–05, representing 0.4% of
all separations and 32% of all separations with adverse effects of any medicine (Table 14).
Their number increased with age, with 81% of such hospitalisations occurring in patients
aged 65 years and over. This probably reflects the fact that older people are both more likely
to take medicines and to be hospitalised. Anticoagulants were the most commonly recorded
medicines with adverse effects, accounting for 32% of the total (9,127 separations), followed
by cardiac-stimulant glycosides and medicines of similar action (3,223 separations). Overall,
most drug-adverse events occurred in hospital (42–91%), but up to 18% happened at home,
depending on the medicine class considered. The proportion of hospitalisations with codes
for adverse effects of medicines used to treat or prevent cardiovascular disease remained
constant from 2003–04 to 2004–05.
A study conducted in Western Australia showed that between 1991 and 2002, rates of drugadverse events causing admission to hospital or extending hospital stay doubled for people
aged 60 years and over (Burgess et al. 2005). In those aged 80 years and over, the increase
was even more marked and cardiovascular medicines were the most frequently associated
with hospitalisations with drug-adverse events. For people aged 60 years and over,
anticoagulants were the most common medicines implicated in drug-adverse events causing
hospitalisation in 2002 and had had the largest increase over time.
41
Table 14: Hospitalisations with adverse effects of medicines used to prevent or treat cardiovascular
disease, 2003–04 and 2004–05
Number separations
Medicine class (ICD-10-AM code)
2003–04
2004–05
8,587
9,127
115
71
37
364
146
91
1,334
1,259
Predominantly β-adrenoreceptor antagonists, not elsewhere classified (Y51.5)
206
204
α-Adrenoreceptor antagonists, not elsewhere classified (Y51.6)
105
115
β-Adrenoreceptor antagonists, not elsewhere classified (Y51.7)
2,411
2,707
Cardiac-stimulant glycosides and drugs of similar action (Y52.0)
2,803
3,223
739
792
Other antidysrhythmic drugs, not elsewhere classified (Y52.2)
1,217
1,363
Coronary vasodilators, not elsewhere classified (Y52.3)
1,254
1,222
Angiotensin-converting-enzyme inhibitors (Y52.4)
1,445
1,564
Other antihypertensive drugs, not elsewhere classified (Y52.5)
2,443
2,803
303
395
Peripheral vasodilators (Y52.7)
56
68
Antivaricose drugs, including sclerosing agents (Y52.8)
10
14
Other and unspecified agents primarily affecting the cardiovascular system (Y52.9)
119
118
Benzothiadiazine derivatives (Y54.3)
441
508
Loop (high-ceiling) diuretics (Y54.4)
773
846
1,588
1,595
Total separations with adverse effects of medicines used to treat or prevent CVD
26,132
28,449
Total separations with adverse effects of any medicine
83,022
90,371
6,841,225
7,018,850
Anticoagulants (Y44.2)
Anticoagulant antagonists, vitamin K and other coagulants (Y44.3)
Antithrombotic drugs (Y44.4)
Thrombolytic drugs (Y44.5)
Salicylates (Y45.1)
Calcium-channel blockers (Y52.1)
Antihyperlipidaemic and antiarteriosclerotic drugs (Y52.6)
Other diuretics (Y54.5)
Total separations
Notes
1.
Some of the medicines listed in this table are used to treat a range of conditions outside the cardiovascular system. The particular condition
for which the medicine was indicated is not recorded.
2.
Hospitalisations with adverse effects of medicines coded as a principal or additional diagnosis are shown.
Source: AIHW National Hospital Morbidity Database.
Australian Council for Safety and Quality in Health Care initiatives
The former Australian Council for Safety and Quality in Health Care (now Australian
Commission on Safety and Quality in Health Care) identified various strategies shown to
reduce medicine problems. These include:
• computerised prescribing by doctors with clinical decision support systems
• computerised drug-adverse event alerts
• individual patient medicine supply in hospitals, where medicines are labelled, supplied
and stored for individual patients
42
• clinical pharmacy services, which provide patient and staff education
• monitoring and medicine review
• effective transfer of information between hospital and community settings
• community-based medicine management and case conferencing, and
• discharge medicine management (Australian Council for Safety and Quality in Health
Care 2004).
The Council sponsored a national medication safety breakthrough collaborative aimed at
reducing patient harm associated with medicines by 50% in participating facilities
(Australian Council for Safety and Quality in Health Care 2005). The collaborative began in
September 2003 with 100 teams from all states and territories focussing on medicine
processes in acute hospitals and improving medicine practices at the interface between acute
hospitals and the community. Many teams achieved a 50% reduction in harm in the area
they chose, such as antithrombotic agents and cardiovascular medicines. Strategies used
included:
• taking a multidisciplinary approach to improvement
• implementing education programs to raise awareness
• revising systems with the potential to cause harm
• developing tools to reduce medicine omission
• developing systems to identify patients at risk of medicine mismanagement or harm
• developing guidelines for using high-risk medicines
• using patient information material and medicine cards to keep patients informed and
involved in their own medicine management, and
• implementing systems for communication with general practitioners.
This initiative is now disseminating knowledge of successful practices to others.
Veterans’ MATES
The Australian Government Department of Veterans’ Affairs developed the Veterans’
Medicines Advice and Therapeutics Education Services (Veterans’ MATES) program to
improve the use of medicines in the veteran community. The program uses data from RPBS
prescription claims to identify veteran patients who may be at risk of drug-adverse events
and provides information that may help improve the management of patients’ medicines.
Veterans’ GPs are the main focus of the program, but it also involves patients, their carers,
community pharmacists and other specialists to encourage better communication and raise
awareness of patients’ chronic conditions (Department of Veterans’ Affairs 2006).
The program is delivered in modules every three months. Modules delivered to date include:
• a review of medicines among veterans who use five or more medicines each month to
discuss the medicines being taken and why, and how patients were managing medicines
and if there were any unwanted side effects (38,500 patients and their 11,000 doctors)
• medicines for heart failure (13,000 patients and their 6,500 doctors)
• heart medicines for patients with diabetes (17,500 patients, their 8,000 doctors and 5,000
community and hospital pharmacies)
• arthritis medicines and their risks for patients with heart failure or diabetes
43
• using multiple medicines safely (46,000 patients and their 12,500 doctors).
Home medicines reviews
The Australian Government introduced the Home Medicines Review (HMR) in October
2001. The HMR is a program where the patient’s GP and a pharmacist collaboratively review
their use of medicines and develop an agreed medicine management plan. It usually entails a
visit to the patient’s home by a pharmacist accredited to conduct medicine reviews, after a
referral from the patient’s GP and consent from the patient.
The objectives of the HMR are: to detect and resolve potential medicine-related problems
that interfere with the desired health outcomes for the patient; to promote collaboration
between the patient, their carer where appropriate, the GP, pharmacists and other relevant
health professionals to improve the patient’s health and quality of life; and to improve
patients’ and health professionals’ knowledge and understanding about medicines.
An Australian study found that HMRs resolved medicine related problems in 56% of cases
and in a further 20% the problem had improved at follow-up (Gilbert et al. 2002).
From the start of the program to April 2005 there were over 70,000 HMRs conducted
nationally (Urbis Keys Young 2005). About 74% of HMRs were for people aged 65 years and
over, and 62% were provided to women. Older men, young people with chronic disease,
Indigenous Australians, people living in rural and remote areas, and people from diverse
cultural and linguistic backgrounds have to date tended to have less access to HMRs than
other Australians. Only about 15% of GPs have made referrals for HMRs so far, indicating
that HMRs have not been used by a large number of patients who might benefit from them.
44
6 Expenditure on cardiovascular
medicines
In 2005 the Australian Government spent $1.8 billion on ‘cardiovascular system’ medicines,
accounting for 31% of the total spent on all pharmaceuticals for which benefits were paid. In
addition, government expenditure on ‘blood and blood-forming organs’ medicines was
$214 million in that year, representing 4% of the total (Table A5).
Serum-lipid-reducing agents (mainly statins) accounted for 55% of the total government
expenditure on cardiovascular system medicines in 2005, while agents acting on the renin–
angiotensin system represented 25%. Platelet aggregation inhibitors excluding heparin (such
as aspirin) accounted for 86% of the total spent on blood and blood-forming organs
medicines in that year.
Four medicines indicated for cardiovascular disease were among the top ten by cost to the
Australian Government in 2005 (Table 15). The cholesterol-lowering medicines atorvastatin
and simvastatin were ranked first and second, costing $481 million and $352 million,
respectively.
Table 15: Top ten prescription medicines by cost to the Australian Government, 2005
Number of PBS/RPBS
prescriptions (’000)
Cost to Australian
Government ($million)
Lowers blood cholesterol
8,439
481
simvastatin*
Lowers blood cholesterol
6,318
352
3
omeprazole
Lowers gastric acid
4,334
169
4
salmeterol and fluticasone
Opens airways
2,817
166
5
clopidogrel*
Antiplatelet agent
2,038
159
6
esomeprazole
Lowers gastric acid
3,296
157
7
olanzapine
Antipsychotic agent
725
151
8
alendronic acid
Lowers bone breakdown
2,211
112
9
pravastatin*
Lowers blood cholesterol
2,062
112
10
pantoprazole
Lowers gastric acid
2,655
105
Rank
Medicine
Action
1
atorvastatin*
2
Note: * Denotes medicine indicated for cardiovascular disease.
Source: Pharmaceutical Benefits Data System, DoHA (unpublished).
Over the period 2001–05, government expenditure on ‘cardiovascular system’ medicines
increased by 26%, while expenditure on ‘blood and blood-forming organs’ medicines rose by
56% (Figure 17 and Table A5). By comparison, government expenditure on all
pharmaceuticals increased by 23% (DoHA unpublished).
Among cardiovascular system medicines, there were increases in expenditure for cardiacstimulants excluding cardiac glycosides (95%), beta-blocking agents (40%), antihypertensives
(37%), serum-lipid-reducing agents (33%) and agents acting on the renin–angiotensin system
(23%); while expenditure fell for cardiac glycosides (–33%), vasodilators used in cardiac
diseases (–19%), diuretics (–16%), antiarrhythmics (–14%) and peripheral vasodilators (–9%)
(Figure 18 and Table A5).
45
Expenditure on all types of blood and blood-forming organs medicines rose between 2001
and 2005: heparin group (59%), platelet aggregation inhibitors excluding heparin (58%),
enzymes (42%), and vitamin K antagonists (20%) (Figure 19 and Table A5).
$ (m illion)
2,000
1,800
1,600
Cardiovascular
drugs
1,400
1,200
Blood and bloodforming organs
drugs
1,000
800
600
400
200
0
2001
2002
2003
2004
2005
Source: Pharmaceutical Benefits Data System, DoHA.
Figure 17: Government expenditure on medicines to prevent and treat cardiovascular disease,
2001–05
46
Serum-lipid-reducing agents
$ (m illion)
1,000
Agents acting on reninangiotensin system
900
Calcium-channel blockers
800
Beta-blocking agents
700
600
Vasodilators used in cardiac
diseases
500
Diuretics
400
Antiarrhythmics
300
Cardiac glycosides
200
Cardiac stimulants excluding
cardiac glycosides
100
Antihypertensives
0
2001
2002
2003
2004
2005
Peripheral vasodilators
Source: Pharmaceutical Benefits Data System, DoHA.
Figure 18: Government expenditure on cardiovascular medicines by class, 2001–05
$ (m illion)
200
180
160
140
Vitamin K antagonists
120
Heparin group
100
Platelet aggregation inhibitors
excluding heparin
80
Enzymes
60
40
20
0
2001
2002
2003
2004
2005
Source: Pharmaceutical Benefits Data System, DoHA.
Figure 19: Government expenditure on blood and blood-forming organs medicines by class,
2001–05
47
7 Discussion
Medicines are a part of most people’s lives. Their use increases with age, and most older
people take more than one medicine. Medicines can save lives, help people stay healthy, cure
some diseases and improve quality of life. But they can also have associated side effects and
problems relating to over-use, under-use, misuse or adverse events.
Cardiovascular disease affects nearly one in five Australians and about 65% report using
medicines for their cardiovascular condition(s), amounting to 2.3 million people.
Government expenditure on medicines commonly used to prevent or treat cardiovascular
disease amounted to $2 billion in 2005, representing 35% of the total spent on all subsidised
medicines. It is in everybody’s interest that cardiovascular medicines are used safely,
responsibly and effectively.
This report documents important changes over the past decade in the supply of medicines
that may be used to prevent and treat cardiovascular disease. In particular, there have been
increases in supply of some blood-pressure-lowering medicines (agents acting on the renin–
angiotensin system, calcium-channel blockers and beta-blockers), some serum-lipid-reducing
agents (statins and ‘other cholesterol and triglyceride reducers’), antithrombotic agents and
antiarrhythmic medicines.
Similarly, between 2000–01 and 2005–06 there were significant changes in how GPs used
medicines to manage people with cardiovascular conditions and risk factors. Specifically, we
observed increased rates of prescription or supply of: agents acting on the renin–angiotensin
system in managing hypertension and diabetes, serum-lipid-reducing agents in managing
ischaemic heart disease and diabetes, antithrombotic agents in managing ischaemic heart
disease, and beta-blocking agents in managing heart failure.
We found a higher rate of supply of some cholesterol-lowering agents (statins) and some
clot-preventing medicines to newly prescribed people in the most socioeconomically
disadvantaged group compared with the least disadvantaged group. This is consistent with
the observed higher prevalence of cardiovascular disease and cardiovascular deaths in the
most disadvantaged group compared with the least disadvantaged (AIHW 2006a). However,
we do not know if the increased medicines supply to the most disadvantaged group meets
their increased need.
The report also describes national initiatives to improve clinical practice relating to
cardiovascular disease and promote quality use of medicines. Results to date show
encouraging improvements in the management of people with hypertension or coronary
heart disease—more patients achieving control of their blood pressure, using bloodpressure-lowering medicines suited to their coexisting health conditions, receiving early clotbusting treatment if having a heart attack, taking aspirin and a cholesterol-lowering agent if
they have coronary heart disease, and taking beta-blocking agents if they have had a heart
attack.
Together, these results suggest that doctors are increasingly following best practice
guidelines for the management of cardiovascular conditions and that national interventions
to this effect may indeed be starting to have a positive impact. However, it is worth noting
that in some cases these improvements were small. On the other hand, we must also keep in
mind that although most people with cardiovascular disease are older people, and therefore
at higher risk of cardiovascular disease, with potentially more to gain with appropriate
treatment, their doctors might deliberately undertreat them for fear of causing drug-adverse
48
events in patients using multiple medicines, due to the lack of good evidence on the
effectiveness of medicines in older people with multiple chronic medical conditions, or in
answer to patients’ preferences (Gurwitz 2004, McLean & Le Couteur 2004, Tinetti et al.
2004).
Our analyses show a high level of discontinuation of medicines that are generally intended
to be taken long term. This represents a significant waste of resources and a lost opportunity
to prevent cardiovascular disease, or delay its progression and complications, with
medicines known to be effective. We do not know for sure why so many people stop taking
their medicines. Although most of the cost of medicines in our study was covered by
government subsidies, suggesting that cost might not be a major factor, Schoen et al.’s work
indicate that one in five sicker Australians omit a medicine owing to cost. Side effects of
medicines may have led to their discontinuation, particularly in people using multiple
medicines—nearly 28,500 hospitalisations were associated with adverse events of
cardiovascular medicines and even in cases which did not require care in hospital, side
effects can be annoying enough to affect persistence with medicines. Remoteness does not
appear to have played a big part because any observed regional differences in persistence
with medicines were small. Factors such as treating conditions with no symptoms, patients’
lack of understanding of their condition or the benefits of treatment, and complexity of
treatment are likely to have played a role. Previous research has shown deficiencies in
communication between patients and health professionals, poor care coordination and
inadequate care of patients with chronic disease in Australia (Schoen et al. 2005).
Our report reveals large disparities in the supply of cardiovascular medicines to newly
prescribed patients—people living in metropolitan areas were dispensed these medicines at
twice the rate of those in rural areas, and 29–58 times the rate of people in remote areas.
Given that deaths from cardiovascular disease are higher in rural and remote areas of
Australia compared with major cities, these inequalities are of particular concern (AIHW
2004a, AIHW 2006a). The BEACH study has shown no differences in the rates at which GPs
manage circulatory problems or prescribe cardiovascular medicines in rural and remote
areas compared with metropolitan areas (AIHW: Knox et al. 2005). However, the availability
of doctors per head of population decreases with increasing geographic remoteness (AIHW
2004b), as does the average number of GP visits per year per head of population (AIHW:
Knox et al. 2005), limiting access to doctors for people in rural and remote areas and
opportunities to manage health conditions and prescribe medicines. It is therefore likely that
the disparities in supply of medicines are due to problems accessing medical services and
medicines in rural and remote areas. We do not know if, and to what extent, people in rural
and remote areas access medicines from other sources such as state and territory government
programs.
Safety is a concern too. Medicines that may be used to prevent or treat cardiovascular disease
were associated with 301 deaths in 2004 and in 29 of these cases they were the main cause of
death. Adverse effects of these medicines were recorded in almost 28,500 hospitalisations in
2004–05, with most of these occurring in patients aged 65 years and over. This figure is
probably a gross underestimate as a large proportion of adverse events are not detected or
recorded. Between 1991 and 2002, rates of drug-adverse events causing admission to hospital
or extending hospital stay doubled for people aged 60 years and over. This is likely to be
related to the observed use of multiple medicines (including complementary medicines)
among older people, raising the potential for adverse medicine interactions, combined with
the higher risk of adverse events in this group. There were also GP reports of patients with
hypertension taking prescription or complementary medicines that could raise blood
pressure. Home medicines reviews, with the potential to detect and prevent medicine related
49
problems, are underused. However, other national initiatives to reduce patient harm from
medicines have achieved good results in participating centres.
The data presented in this report were drawn from the best national sources available, none
of which is designed to elicit the sort of information we require to make a good assessment
of whether medicines are used appropriately. The Pharmaceutical Benefits Data System
allows us to build prescription histories for individual patients, but does not record the
health condition for which a medicine was prescribed or the dose and medicine regimen
prescribed. It also lacks coverage of patients dispensed unsubsidised prescriptions. The
BEACH study gives us a valuable cross sectional snapshot of what happens in general
practice, but does not provide information on how individual patients are managed over
time. The National Health Survey asks participants about medicines taken for selected
conditions only, and many people do not know which medicines they take for which
condition, so the information on medicines in the survey is likely to be incomplete and
unreliable. The National Hospital Morbidity Database contains information on episodes of
care and drug-adverse events but does not record medicines used in hospital or patient
identifiers so individual patients cannot be tracked through the system over time. Unique
patient identifiers are needed to enhance patient transitions across parts of the health system
and support quality use of medicines and patient safety.
The National Chronic Disease Strategy recognises that care for people with chronic disease,
such as cardiovascular disease, generally involves multiple health care providers across
multiple settings, including general practice, community health, hospitals, private providers
and community and non-government organisations (National Health Priority Council 2006).
It calls for integrated provision of disease prevention and care across services, settings,
sectors and over time. The strategy states that multidisciplinary care must focus on the
patient as a whole person, incorporate prevention, self-management and coexisting
conditions, and be responsive to changing patient needs. The National Strategy for Quality
Use of Medicines recognises the central role of health consumers and active partnerships in
achieving quality use of medicines (DoHA 2002).
The approach taken for this report is narrow—focusing exclusively on cardiovascular
disease. It does not reflect the reality of people living with multiple coexisting conditions.
About 80% of Australians aged 65 years and over—the age group most affected by
cardiovascular disease—have three or more chronic conditions (AIHW 2006a). Managing
coexisting conditions affects the treatment choices health professionals make for their
patients and the choices patients make for themselves. Our capacity to get some insight into
this complexity is constrained by the data sources available. National administrative data
sources in their current form do not make enough information available to allow linking of
patient records. Such linkages between records of medical services delivered, medicines
supplied, hospitalisations and deaths are needed to assess the quality of care given to
patients at a national level and its impact on outcomes for them. Without linkages, we are
restricted to using inadequate data sources that can at best provide only a broad picture,
with no detail, from limited perspectives. Until individual electronic health records are
adopted, or linking of health records nationally becomes possible, an integrated,
multidimensional view of the whole person and their interaction with the whole health
system, across all health care settings, throughout their life, will be lacking. At the state level,
Western Australia and New South Wales have already established systems and protocols to
link health records (Brook et al. 2005, Kelman et al. 2002, The Sax Institute 2007).
Arrangements to do this at the national level have been proposed (Kelman et al. 2007).
50
This report has concentrated on some aspects of the quality use of medicines for
cardiovascular health in Australia, but it has not looked into another side of the equation—
the extent of excessive prescribing of medicines for those people at lower risk of
cardiovascular disease. We hope to be able to tackle this issue in the near future.
51
Appendix
Appendix tables
Table A1: Supply of cardiovascular medicines in selected OECD countries, 2004
Medicine class
Country
ARA
CCB
BBA
DIU
AHYP
ART
GLY
CHOL
DDD/1,000 population/day
Australia
146.9
77.0
25.5
39.4
5.2
2.2
5.3
161.8
Belgium
91.3
40.4
66.6
43.7
5.4
8.0
5.0
104.1
105.1
69.9
71.3
95.5
12.2
5.6
7.1
65.0
85.1
46.2
29.9
111.5
2.7
1.6
6.3
67.2
125.3
48.3
68.1
61.9
1.7
1.8
6.6
81.7
Germany
143.8
48.8
67.6
65.9
11.6
2.3
10.1
57.3
Greece
149.4
68.6
30.7
35.7
6.7
5.5
9.9
84.0
80.9
31.5
46.4
67.3
1.4
3.3
3.2
75.2
99.1
46.6
39.4
45.4
n/a
1.3
4.4
110.0
109.7
37.0
18.3
42.4
0.3
7.3
6.8
71.1
88.8
63.3
42.8
31.7
10.7
4.3
6.6
31.5
85.6
40.7
54.7
87.3
1.9
1.1
6.5
75.2
Czech
Republic
Denmark
Finland
(a)
(a)
(b)
Iceland
(a)
Norway
Portugal
(c)
Slovak
Republic
Sweden
ARA
(a)
agents acting on renin–angiotensin system
CCB
calcium-channel blockers
BBA
beta-blocking agents
DIU
diuretics
AHYP antihypertensives
ART
antiarrhythmics
GLY
cardiac glycosides
CHOL serum-lipid-reducing agents
n/a
not available
(a)
Data for Denmark, Finland, Norway and Sweden cover supply of medicines in the community and in hospitals.
(b)
Data for Germany refer to health insured persons only.
(c)
Data for Portugal does not include medicines supplied to civil servants, army and police.
Note: Data shown here refer to prescription medicines supplied in the community. It does not include medicines supplied in hospital unless
otherwise specified above.
Source: OECD Health Data 2006.
52
Table A2: Persistence with medicines by region of patient residence
Proportion of patients persistent at:
Medicine class
6 months
Region of residence
Males
24 months
Females
Males
Females
% (95% CI)
HMG CoA reductase inhibitors (statins)
Metropolitan
82.17 (81.99–82.34)
82.79 (82.61–82.97)
62.51 (62.25–62.77)
63.62 (63.35–63.89)
Rural
85.14 (84.92–85.36)
85.61 (85.38–85.84)
68.35 (68.00–68.69)
68.92 (68.56–69.28)
Remote
82.47 (81.49–83.40)
82.09 (80.99–83.14)
62.76 (61.26–64.22)
61.97 (60.30–63.60)
Metropolitan
87.38 (87.10–87.65)
88.49 (88.27–88.70)
71.82 (71.34–72.29)
74.21 (73.84–74.58)
Rural
89.73 (89.40–90.05)
90.41 (90.14–90.67)
76.36 (75.77–76.94)
78.70 (78.23–79.16)
Remote
86.99 (84.98–88.75)
89.71 (88.11–91.11)
72.98 (69.65–76.01)
75.94 (73.19–78.45)
Metropolitan
88.82 (88.41–89.22)
90.87 (90.57–91.16)
75.59 (74.89–76.27)
78.65 (78.13–79.16)
Rural
91.92 (91.41–92.40)
92.76 (92.37–93.13)
81.13 (80.24–81.99)
83.16 (82.49–83.80)
Remote
88.78 (85.50–91.35)
91.49 (89.08–93.39)
80.60 (76.02–84.40)
84.05 (80.41–87.07)
Metropolitan
87.56 (87.32–87.79)
88.03 (87.81–88.25)
72.74 (72.34–73.13)
74.23 (73.85–74.61)
Rural
89.27 (89.00–89.53)
89.65 (89.38–89.91)
76.55 (76.09–77.00)
77.84 (77.38–78.30)
Remote
84.47 (83.05–85.78)
84.98 (83.54–86.30)
68.41 (66.14–70.57)
68.64 (66.26–70.89)
Metropolitan
88.68 (88.06–89.27)
90.83 (90.34–91.29)
75.02 (73.92–76.08)
78.48 (77.56–79.36)
Rural
91.24 (90.52–91.91)
92.68 (92.09–93.22)
80.98 (79.70–82.19)
83.03 (81.93–84.07)
Remote
84.91 (80.65–88.30)
87.48 (84.03–90.23)
71.88 (65.14–77.54)
76.65 (71.31–81.13)
Metropolitan
73.96 (73.60–74.32)
74.14 (73.80–74.48)
51.09 (50.57–51.61)
51.41 (50.92–51.90)
Rural
76.67 (76.24–77.10)
76.98 (76.56–77.39)
54.54 (53.91–55.17)
56.05 (55.44–56.65)
Remote
74.52 (72.48–76.44)
77.36 (75.33–79.25)
53.70 (50.83–56.48)
55.32 (52.31–58.22)
Metropolitan
82.55 (82.05–83.03)
83.97 (83.50–84.43)
53.45 (52.52–54.37)
57.33 (56.40–58.25)
Rural
84.17 (83.57–84.75)
85.24 (84.61–85.85)
57.36 (56.21–58.50)
60.69 (59.42–61.93)
80.44 (77.19–83.28)
83.43 (79.88–86.41)
50.64 (44.99–56.01)
55.36 (48.48–61.69)
Metropolitan
89.71 (89.44–89.97)
89.65 (89.33–89.96)
75.05 (74.56–75.54)
75.34 (74.77–75.90)
Rural
90.69 (90.33–91.04)
90.82 (90.39–91.24)
77.66 (77.00–78.31)
78.16 (77.38–78.91)
Remote
89.06 (87.20–90.66)
89.75 (87.42–91.67)
76.88 (73.76–79.68)
74.30 (70.07–78.03)
Angiotensin II antagonists (plain)
Angiotensin II antagonists (combin.)
ACE inhibitors (plain)
ACE inhibitors (combin.)
Beta-blocking agents
Warfarin
Remote
Other antithrombotic agents
(a)
(a)
Includes clopidogrel, dipyridamole and ticlopidine.
Notes
1.
The study included newly prescribed patients only.
2.
Rates age standardised to the Australian population at 30 June 2001.
3.
Region of residence of patients was determined at the time of their first prescription being dispensed.
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
53
Table A3: Prescriptions supplied to newly prescribed patients by socioeconomic level
Medicine class
Least disadvantaged group
Most disadvantaged group
Rate ratio
Rate per 100,000 (95% CI)
HMG COA reductase
inhibitors (statins)
Males
Females
Other antithrombotic agents
Males
416.0 (412.8–419.1)
471.7 (468.3–475.2)
1.13
363.8 (360.9–366.8)
461.5 (458.1–464.9)
1.27
122.7 (121.0–124.4)
128.4 (126.6–130.2)
1.05
83.0 (81.6–84.3)
89.7 (88.1–91.2)
1.08
(a)
Females
(a)
Includes clopidogrel, dipyridamole and ticlopidine.
Notes
1.
The study included newly prescribed patients only.
2.
Socioeconomic level coded according to SEIFA. Rates shown for Level 1 (least disadvantaged) and Level 5 (most disadvantaged).
For details see Methods section.
3.
Rates age standardised to the Australian population at 30 June 2001.
4.
The rate ratio is calculated as the rate in the most disadvantaged group divided by the rate in the least disadvantaged group.
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
Table A4: Persistence with medicines by level of socioeconomic disadvantage
Proportion of patients persistent at:
6 months
Medicine class
Least
disadvantaged
24 months
Most
disadvantaged
Least
disadvantaged
Most
disadvantaged
% (95% CI)
HMG COA reductase
inhibitors (statins)
Males
83.15 (82.85–83.45)
81.72 (81.42–82.02)
63.64 (63.18–64.10)
62.80 (62.35–63.25)
Females
83.81 (83.50–84.12)
82.21 (81.91–82.51)
65.16 (64.86–65.63)
63.01 (62.55–63.46)
Males
89.43 (88.95–89.89)
90.21 (89.75–90.65)
74.96 (74.08–75.82)
75.75 (74.89–76.58)
Females
89.56 (89.00–90.10)
89.41 (88.83–89.96)
75.66 (74.67–76.62)
75.34 (74.33–76.32)
Other antithrombotic
(a)
agents
(a)
Includes clopidogrel, dipyridamole and ticlopidine.
Notes
1.
The study included newly prescribed patients only.
2.
Socioeconomic level coded according to SEIFA. For details see Methods section.
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
54
Table A5: Government expenditure on selected medicines (constant prices), 2001–05
Medicine class
2001
2002
2003
2004
2005
% change 2001–05
($ million)
Cardiac glycosides
3.4
3.2
3.1
2.9
2.5
–33.2
14.5
14.2
13.6
13.7
12.7
–14.2
0.2
0.2
0.6
2.9
4.9
95.1
Vasodilators used in
cardiac diseases
49.3
47.6
44.5
44.4
41.6
–18.6
Antihypertensives
11.7
11.5
11.0
14.3
18.6
37.0
Diuretics
26.7
26.1
24.8
25.3
22.9
–16.4
0.1
0.1
0.1
0.1
0.1
–8.7
57.1
67.0
76.6
89.6
94.8
39.7
Calcium-channel
blockers
160.9
166.3
168.4
172.8
165.8
2.9
Agents acting on renin–
angiotensin system
347.2
384.4
423.0
459.2
450.4
22.9
Serum-lipid-reducing
agents
662.9
752.9
848.0
967.2
987.1
32.8
1,334.3
1,473.8
1,614.0
1,792.6
1,801.5
25.9
Vitamin K antagonists
8.3
9.1
9.9
10.9
10.4
19.7
Heparin group
6.8
11.4
14.6
14.7
16.5
58.7
76.7
108.7
140.6
169.1
184.9
58.5
1.3
1.3
2.5
3.0
2.2
42.3
93.2
130.5
167.6
197.8
214.2
56.5
4,445.2
4,883.4
5,235.2
5,767.1
5,803.7
23.4
Antiarrhythmics
Cardiac-stimulants
excluding cardiac
glycosides
Peripheral vasodilators
Beta-blocking agents
All cardiovascular
medicines
Platelet aggregation
inhibitors excluding
heparin
Enzymes
All blood and bloodforming organs
medicines
All medicines
Note: All figures are expressed in constant price terms to remove the effects of inflation and allow comparison of expenditure in different years on
an equal dollar-for-dollar basis.
Source: Pharmaceutical Benefits Data System, DoHA (unpublished).
55
Appendix figures
Patients persistent
100%
90%
80%
HMG COA
reductase
inhibitors (statins)
70%
60%
50%
40%
30%
20%
10%
0%
0
6
12
18
24
Months
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
Figure A1: Persistence with HMG COA reductase inhibitors (statins)
Patients persistent
100%
Angiotensin II
antagonists
(combinations)
ACE inhibitors
(combinations)
90%
80%
70%
Angiotensin II
antagonists
(plain)
ACE inhibitors
(plain)
60%
50%
40%
Beta-blocking
agents
30%
20%
10%
0%
0
6
12
Months
18
24
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
Figure A2: Persistence with selected medicines with blood-pressure-lowering effect
56
Patients persistent
100%
90%
80%
Other
antithrombotic
agents
70%
Warfarin
60%
50%
40%
30%
20%
10%
0%
0
6
12
Months
18
Source: AIHW analysis of data supplied by DoHA from the Pharmaceutical Benefits Data System.
Figure A3: Persistence with antithrombotic agents
57
24
The Anatomical Therapeutic Chemical (ATC)
classification system
Developed by the World Health Organisation, the ATC classification is the Australian
standard for classifying medicines. In this system the medicines are grouped according to the
system on which they act and their chemical, pharmacological and therapeutic properties.
Medicines are classified into five levels. That part of the ATC classification relevant to
cardiovascular disease is shown here.
ATC code
ATC Level 1
B
Blood and
blood-forming
organs
B01
ATC Level 2
ATC Level 3
ATC Level 4
Antithrombotic
agents
B01AA
Vitamin K antagonists
B01AA03
warfarin
B01AB
Heparin group
B01AB05
enoxaparin
B01AC
Platelet aggregation
inhibitors excl. heparin
B01AC06
aspirin
B01AD
Enzymes
B01AD01
C01
C01A
streptokinase
Cardiovascular
system
Cardiac therapy
Cardiac glycosides
C01AA
Digitalis glycosides
C01AA05
C01B
(a)
Antithrombotic
agents
B01A
C
ATC Level 5
digoxin
Antiarrhythmics,
class I and III
C01BA
Antiarrhythmics, class
IA
C01BA01
quinidine
C01BB
Antiarrhythmics, class
IB
C01BB01
lignocaine
C01BC
Antiarrhythmics, class
IC
C01BC04
flecainide
C01BD
Antiarrhythmics, class
III
C01BD01
amiodarone
58
ATC code
ATC Level 1
ATC Level 2
C01C
ATC Level 3
ATC Level 4
Adrenergic and
dopaminergic agents
C01CA24
adrenaline
C01D
Vasodilators used
in cardiac
diseases
C01DA
Organic nitrates
C01DA14
isosorbide
mononitrate
C01DX
Other vasodilators
used in cardiac
diseases
C01DX16
C02A
nicorandil
Antihypertensives
Antiadrenergic
agents, centrally
acting
C02AB
Methyldopa
C02AB01
methyldopa
C02AC
Imidazoline receptor
agonists
C02AC01
C02C
clonidine
Antiadrenergic
agents,
peripherally acting
C02CA
Alpha adrenoceptor
blocking agents
C02CA01
C02D
(a)
Cardiac-stimulants
excluding cardiac
glycosides
C01CA
C02
ATC Level 5
prazosin
Arteriolar smooth
muscle, agents
acting on
C02DB
Hydrazinophthalazine
derivatives
CO2DB02
hydralazine
C02DC
Pyrimidine derivatives
C02DC01
minoxidil
C02DD
Nitroferricyanide
derivatives
C02DD01
sodium nitroprusside
59
ATC code
C03
ATC Level 1
ATC Level 2
ATC Level 3
ATC Level 4
Low-ceiling
diuretics, thiazides
C03AA
Thiazides, plain
C03AA01
bendrofluazide
C03B
Low-ceiling
diuretics,
excluding
thiazides
C03BA
Sulfonamides, plain
C03BA11
indapamide
C03C
High-ceiling
diuretics
C03CA
Sulfonamides, plain
C03CA01
frusemide
C03CC
Aryloxyacetic acid
derivatives
C03CC01
ethacrynic acid
C03D
Potassium-sparing
agents
C03DA
Aldosterone
antagonists
C03DA01
spironolactone
C03DB
Other potassiumsparing agents
C03DB01
amiloride
C03E
Diuretics and
potassium-sparing
agents
combinations
C03EA
Low-ceiling diuretics
and potassium-sparing
agents
C03EA01
C04A
(a)
Diuretics
C03A
CO4
ATC Level 5
hydrochlorothiazide
with amiloride
Peripheral
vasodilators
Peripheral
vasodilators
C04AD
Purine derivatives
C04AD03
oxpentifylline
C04AX
Other peripheral
vasodilators
C04AX02
phenoxybenzamine
hydrochloride
60
ATC code
C07
ATC Level 1
ATC Level 2
ATC Level 3
ATC Level 4
Beta-blocking
agents
C07A
Beta-blocking
agents, plain
C07AA
Beta-blocking agents,
plain, non-selective
C07AA07
sotalol
C07AB
Beta-blocking agents,
plain, selective
C07AB03
atenolol
C07AG
Alpha- and betaadrenoceptor blocking
agents
C07AG01
C08
carvedilol
Calcium-channel
blockers
C08C
Selective calciumchannel blockers
with mainly
vascular effects
C08CA
Dihydropyridine
derivatives
C08CA01
amlodipine
C08D
Selective calciumchannel blockers
with direct cardiac
effects
C08DA
Phenylalkylamine
derivatives
C08DA01
verapamil
C08E
Non-selective
calcium-channel
blockers
C08EX
Other non-selective
calcium-channel
blockers
C08EX02
C09
C09A
ATC Level 5
perhexiline
Agents acting on
the renin–
angiotensin
system
ACE inhibitors,
plain
C09AA
ACE blockers
C09AA05
ramipril
61
(a)
ATC code
ATC Level 1
ATC Level 2
C09B
ATC Level 3
ATC Level 4
(a)
ACE inhibitors,
combinations
C09BA
ACE blockers and
diuretics
C09BA04
perindopril and
indapamide
C09C
Angiotensin II
antagonists
C09CA
Angiotensin II
antagonists, plain
C09CA04
irbesartan
C09D
Angiotensin II
antagonists,
combinations
C09DA
Angiotensin II
antagonists and
diuretics
C09DA04
C10
ATC Level 5
irbesartan and
hydrochlorothiazide
Serum-lipidreducing agents
C10A
Cholesterol and
triglyceride
reducers
C10AA
HMG COA reductase
inhibitors
C10AA05
atorvastatin
C10AB
Fibrates
C10AB04
gemfibrozil
C10AC
Bile acid sequestrants
C10AC01
cholestyramine
C10AD
Nicotinic acid and
derivatives
C10AD02
nicotinic acid
C10AX
Other cholesterol and
triglyceride reducers
C10AX09
ezetimibe
(a) One generic medicine is shown as an example at this level.
62
Data sources
AIHW National Hospital Morbidity Database: contains demographic, diagnosis, procedure
and duration of stay information on episodes of care for patients admitted to hospital. The
collection is maintained by the AIHW using data supplied by state and territory health
authorities.
AIHW National Mortality Database: contains information on the cause of death supplied by
the medical practitioner certifying the death or by a coroner. Registration of deaths is the
responsibility of the state and territory registrars of births, deaths and marriages. Registrars
provide the information to the ABS for coding of cause of death and then it is given to the
AIHW.
BEACH (Bettering the evaluation and care of health) survey of general practice: an
ongoing national cross-sectional survey looking at aspects of general practice in Australia,
conducted by the Australian General Practice Statistics and Classification Centre (an AIHW
collaborating unit within the Family Medicine Research Centre, University of Sydney).
BEACH began in April 1998 and involves a random sample of about 1,000 general
practitioners per year, each of whom records details on 100 consecutive patient encounters.
Pharmaceutical Benefits Data System: held at the Australian Government Department of
Health and Ageing (DoHA), it is used to monitor expenditure and use of prescription
medicines subsidised by the Pharmaceutical Benefits Scheme (PBS) and the Repatriation PBS
(RPBS). The database contains information pertinent to the payment of claims for
pharmaceuticals from Medicare Australia for medicines subsidised by the PBS and the RPBS.
Inpatient hospital prescribing is not included. It is the source for data on subsidised scripts in
the Drug Utilisation Sub-Committee database. The data are based on the date of supply or
dispensing of prescriptions.
Drug Utilisation Sub-Committee database: held at the Australian Government Department
of Health and Ageing (DoHA), it monitors the community (that is, non-public hospital) use
of prescription medicines in Australia. The database combines information supplied by
Medicare Australia on medicines subsidised by the Pharmaceutical Benefits Scheme (PBS)
and the Repatriation PBS, and an estimate of unsubsidised prescriptions (under co-payment
and private prescriptions) calculated from a validated sample of community based
pharmacies from the continuous Pharmacy Guild Survey. Inpatient hospital prescribing is
not included.
National Health Survey 2004–05: conducted by the ABS, to obtain national information on
the health status of Australians, their use of health services and other actions people had
taken for their health, and health-related aspects of their lifestyle. The 2004–05 survey
collected information from a sample of 25,900 people across all ages from all states and
territories from August 2004 to June 2005. One adult and one child (where applicable) from
each sampled dwelling were included in the survey. Information about use of medicines was
collected as reported by participants for the following conditions only: asthma, circulatory
conditions, diabetes, arthritis, osteoporosis and mental wellbeing. Medicines include
pharmaceuticals, vitamin and mineral supplements, and natural and herbal medicines.
63
Methods
Codes used in this report
Data
Disease / problem / medicine class
Deaths / Hospital
separations (Drugs,
medicaments and
biological substances
causing adverse effects in
therapeutic use)
Anticoagulants
Number of medicines
taken for health condition
(NHS)
Classification
Code
ICD-10 /
ICD-10-AM
Y44.2
Anticoagulant antagonists, vitamin K and
other coagulants
Y44.3
Antithrombotic drugs
Y44.4
Thrombolytic drugs
Y44.5
Salicylates
Y45.1
Predominantly β-adrenoreceptor
antagonists, not elsewhere classified
Y51.5
α-Adrenoreceptor antagonists, not
elsewhere classified
Y51.6
β-Adrenoreceptor antagonists, not
elsewhere classified
Y51.7
Cardiac-stimulant glycosides and drugs of
similar action
Y52.0
Calcium-channel blockers
Y52.1
Other antidysrhythmic drugs, not elsewhere
classified
Y52.2
Coronary vasodilators, not elsewhere
classified
Y52.3
Angiotensin-converting-enzyme inhibitors
Y52.4
Other antihypertensive drugs, not
elsewhere classified
Y52.5
Antihyperlipidaemic and antiarteriosclerotic
drugs
Y52.6
Peripheral vasodilators
Y52.7
Antivaricose drugs, including sclerosing
agents
Y52.8
Other and unspecified agents primarily
affecting the cardiovascular system
Y52.9
Benzothiadiazine derivatives
Y54.3
Loop (high-ceiling) diuretics
Y54.4
Other diuretics
Y54.5
Hypertensive disease
06
Angina and other ischaemic heart diseases
07,08
Cerebrovascular diseases
11
Oedema and heart failure
12
Diseases of arteries, arterioles and
capillaries
13
Other diseases of the circulatory system
64
09,10,14,15,16,17,18,19,20
Data
Disease / problem / medicine class
General practice (BEACH)
Arrhythmia (atrial fibrillation/flutter, paroxysmal
tachycardia, cardiac arrhythmia NOS)
Classification
ICPC/ICPC-2 PLUS
Diabetes (diabetes; insulin-dependent, diabetes; noninsulin-dependent, gestational diabetes)
K78, K79,
K80
T89, T90,
W85
Heart failure
K77
Hypertension (uncomplicated hypertension,
hypertension with involvement of target organs,
hypertension pre-eclamptic, hypertension in
pregnancy)
K86, K87
W81002
W81003
Ischaemic heart disease (ischaemic heart disease
without angina, Ischaemic heart disease with angina)
K74, K76
Lipid disorder (lipid disorder, lipodystrophy)
T93
T99075
Peripheral vascular disease (Claudication; intermittent,
Buergers disease, peripheral vascular disease,
gangrene, ischaemia; limb (gangrene))
K9201
K92001
K92003
K92004
K92006
Stroke (stroke/cerebrovascular accident)
PBS medicines in data set
analysed for concordance with
medicine
Code
Antithrombotic agents
K90
PBS
warfarin
2843P
2209G
2844Q
2211J
aspirin
8202Q
clopidogrel
8358X
dipyridamole
8335Q
dipyridamole with aspirin
8382E
ticlopidine
2095G
Beta-blocking agents
oxprenolol
2942W
2961W
pindolol
3062E
3065H`
propanolol
2565B
2566C
2899N
sotalol
8398B
2043M
atenolol
1081X
bisoprolol
8604W
8605X
8606Y
metoprolol succinate
8818D
8732N
8733P
8734Q
8735R
metoprolol tartrate
1324Q
1325R
65
Data
PBS medicines in data set
analysed for concordance with
medicine (continued)
Disease / problem / medicine class
Classification
Code
carvedilol
8742D
8255L
8256M
8257N
8258P
labetalol
1566K
1567L
ACE inhibitors (plain)
captopril
1147J
1148K
1149L
8760C
enalapril
1370D
1368B
1369C
fosinopril
1182F
1183G
lisinopril
2456G
2457H
2458J
perindopril
3050M
3051N
8704D
quinapril
1968N
1969P
1970Q
ramipril
1944H
1945J
1946K
8470T
8668F
8937J
trandolapril
2791X
2792Y
2793B
8758Y
ACE inhibitors (combinations)
enalapril with hydrochlorothiazide
8477E
fosinopril with hydrochlorothiazide
8400D
8401E
perindopril with indapamide
8449Q
quinapril with hydrochlorothiazide
8589C
8590D
Angiotensin II antagonists (plain)
candesartan
8295N
8296P
8297Q
8889W
eprosartan
8397Y
8447N
irbesartan
8246B
8247C
8248D
telmisartan
8355R
8356T
66
Data
Disease / problem / medicine class
PBS medicines in data set
analysed for concordance with
medicine (continued)
Angiotensin II antagonists (combinations)
candesartan with hydrochlorothiazide
Classification
Code
8504N
eprosartan with hydrochlorothiazide
8624X
irbesartan with hydrochlorothiazide
8404H
8405J
telmisartan with hydrochlorothiazide
8622T
8623W
HMG COA reductase inhibitors (statins)
atorvastatin
8213G
8214H
8215J
8521L
fluvastatin
8023G
8024H
pravastatin
2833D
2834E
8197K
8829Q
simvastatin
2013Y
2011W
2012X
8173E
8313M
BEACH study data analysis
The methods used to collect and analyse BEACH data are described in detail in AIHW: Britt
et al. 2005. Here is a brief account of the method used to analyse data shown in this report.
Rates of prescription or supply of medicines by general practitioners were compared for the
period 2000–01 to 2005–06. Statistical significance was assessed based on a linear trend over
the years, with non-overlapping confidence intervals between the 2000–01 results and the
2005–06 results. These trends were analysed using SAS V8.2 regression procedures, adjusting
the standard error to allow for the design effect of the cluster sample.
Where significant changes over time were detected, we calculated the estimated annual rate
of change. This is expressed as the mean annual increase or decrease over the study period in
the number of general practice encounters for that problem where a particular medicine was
prescribed or supplied, occurring in Australia each year.
Extrapolated estimates were calculated by multiplying the encounter rate for 2000–01 by the
number of unreferred attendances (A1 and A2 items) claimed through Medicare in that year
to give the estimated number of encounters at which a particular medicine was prescribed or
supplied. The same was done for 2005–06. Where the change was linear over time, the
difference between the two estimates was averaged over 5 years to give the estimated annual
rate of change in encounters.
67
Analysis of concordance with medicines
The Australian Government Department of Health and Ageing (DoHA) holds the
Pharmaceutical Benefits Data System, which contains national prescribing information on
medicines subsidised by the Pharmaceutical Benefits Scheme (PBS) and the Repatriation PBS
(RPBS) (see Box 1 in chapter 3). For medicines in the PBS and RPBS, the patient pays for the
cost of a medicine up to the co-payment amount and the government pays the balance of the
cost, if this is more than the co-payment amount. All prescriptions for which this
government subsidy is paid are recorded in the database. Those prescriptions that fall below
the co-payment level, and therefore attract no subsidy, are not recorded.
In 2002 it became compulsory to record Medicare numbers for patients being dispensed
subsidised PBS and RPBS medicines. This allows the capacity to build prescription histories
for individual patients as well as providing information on their age, sex and postcode of
residence.
Data
We obtained from DoHA anonymous individual patient records of PBS medicines supplied
over the period 1 January 2002–1 June 2006 for selected medicines commonly used in the
prevention and treatment of CVD. Each data record included:
•
•
•
•
•
•
unique patient identifier number (PIN)
patient 5 year age group, sex and postcode of residence
date of supply of prescription
patient beneficiary category (general, concessional or repatriation and safety net status)
PBS item number
number of prescriptions supplied.
The following medicine classes were selected for analysis:
1.
2.
3.
4.
5.
6.
7.
8.
HMG COA reductase inhibitors (statins)
plain angiotensin II antagonists
combination angiotensin II antagonists
plain ACE inhibitors
combination ACE inhibitors
beta-blocking agents
warfarin
other antithrombotic agents (including clopidogrel, dipyridamole and ticlopidine).
We defined cohorts of patients by medicine class, as shown above. We followed each cohort
over the study period and confined the analyses to medicines class; that is, we did not look
at medicine switching within each medicine class or between medicine classes.
Inclusion and exclusion criteria
To ensure uniform populations for the medicines studied, we included only newly
prescribed patients, defined as those with no scripts dispensed in the 12 months before the
patient’s first supply for each of the medicine classes, resulting in an effective study period of
15 January 2003–27 June 2006.
We included only patients who had been dispensed at least two prescriptions without
discontinuation between them (see definition of persistence below), suggesting medicine use
beyond a single prescription.
68
For the cohorts using ‘HMG CoA reductase inhibitors (statins)’ and ‘other antithrombotic
agents’, we included patients in all beneficiary categories as all medicine items in these
classes cost more than the co-payment level for general patients. Therefore, all prescriptions
for these items are recorded in the Pharmaceutical Benefits Data System.
For all the other cohorts, we excluded general patients and focused the analyses on patients
who had concessional or repatriation status for the whole study period. This was done
because the Pharmaceutical Benefits Data System covers only subsidised prescriptions and
many medicines in classes 2 to 7 above fall below the general co-payment level, so
prescriptions are recorded only for concessional/repatriation patients and general patients
on safety net. General patients can also move in and out of the safety net during each
calendar year. Furthermore, patients may have changed their beneficiary status over the
course of the study. These factors result in incomplete coverage in the database of
prescriptions for these medicines supplied to general patients and inadequate follow-up of
patients who changed their beneficiary status.
Records for patients dispensed more than one prescription for the same medicine on any
given date were also excluded.
Records with ‘dummy’ PINs, used by data entry staff when patient identifying information
was lacking, and records with missing information on age, sex or postcode were excluded as
well.
Measures of concordance
In assessing concordance with medicines, we looked at compliance and persistence
according to the definitions and measures in Halpern et al. 2006.
Compliance was defined as taking medicines at the prescribed frequency and dose and was
measured using the medicine possession ratio (MPR).
MPR = days supplied/days between consecutive scripts dispensed
We measured MPR over the first 12 months from the start of therapy. We defined those
patients with MPR of 80% or more as compliant and calculated the proportion of compliant
patients in each cohort.
Persistence was defined as the continued use of medicines for the specified treatment period,
which in the case of the medicines indicated for cardiovascular disease included in this study
was assumed to be lifelong. It was measured from the start of therapy (first date of medicine
supply—index date) until the date of treatment discontinuation or the end of the study
period. Treatment discontinuation was defined as ≥ 90 days between one medicine supply
and the subsequent supply of any medicine in the same class (that is, missed two script
periods). Persistence was measured by
• percentage of patients persistent at 6 months, 12 months, 18 months and 24 months
from the index date (using Kaplan–Meier analysis)
• average duration of persistence.
The 95% confidence intervals for persistence were calculated using the methods presented in
Hosmer & Lemeshow (1999).
69
Analysis of inequalities
To measure inequalities in the supply of medicines, we looked at differences between
populations by socioeconomic indexing and geographical classification.
Socioeconomic indexing for area (SEIFA) is based on the Index of Relative Socioeconomic
Disadvantage (IRSD), which was constructed by the ABS to classify geographic areas on the
basis of social and economic information (ABS 2003). The IRSD is derived from social and
economic characteristics of a Statistical Local Area (SLA), such as income, educational
attainment, unemployment, jobs in various occupations and variables that reflect
disadvantage.
Individual patients were classified into fifths of socioeconomic disadvantage, based on the
IRSD value for the SLA of usual residence. SLA estimates were assigned to patients
according to their postcode by using postcode to SLA conversion factors. Level 1 includes
the least disadvantaged households, while Level 5 covers the most disadvantaged
households. Note that the IRSD relates to the average disadvantage of all people living in an
SLA and does not necessarily reflect an individual’s socioeconomic status. Rates were
calculated for males and females separately, age standardised to the Australian population
as at 30 June 2001.
Geographical classification uses the ABS Australian Standard Geographical Classification
(ASGC) Remoteness Areas Classification to map regional areas by grouping areas with
similar characteristics together (AIHW 2004c).
The ASGC Remoteness Areas assigns each SLA to one of six regional categories: major cities,
inner regional, outer regional, remote, very remote and migratory. These categories were
then regrouped into three larger zones: metropolitan, rural and remote. SLA estimates were
assigned to patients using the postcode to SLA conversion factors. Rates were calculated for
males and females separately, age standardised to the Australian population as at 30 June
2001.
Limitations of the study
Information on the diagnosis for which the medicines were prescribed is not recorded in the
Pharmaceutical Benefits Data System. We assumed that the medicines studied had been
prescribed to prevent or treat a cardiovascular condition, and were therefore intended for
long-term use, but this may not have been true for all patients in the study. However,
cardiovascular conditions are by far the most common indication for those medicines that
can be used to treat other conditions.
Likewise, information on the dosing regime prescribed is not recorded in the Pharmaceutical
Benefits Data System. We assumed a daily dose equal to the pack dose dispensed and
medicine dosing regimes as set out in the Australian Medicines Handbook 2006, but there
are instances where doctors might validly vary these, such as in older patients, in patients
with coexisting conditions or those taking multiple medicines.
The database does not record patients’ date of death, so we may have included in our
analysis time periods beyond which some individuals were alive. This would result in an
overestimation of discontinuation rates for medicines for those individuals.
In the case of warfarin and beta-blocking agents, there are some indications where these
medicines are prescribed for a limited period only. As the database does not contain
information to allow us to identify these patients, we could not exclude them from the
analysis, resulting in overestimation of discontinuation rates for these medicines.
70
National bodies with responsibility for quality use of
medicines
Australian Commission on Safety and Quality in Health Care
The Australian Commission on Safety and Quality in Health Care was established by
Australian Health Ministers in 2006 to lead and coordinate national efforts to improve health
care safety and quality. It succeeded the Australian Council for Safety and Quality in Health
Care which operated from 2000 to 2005.
Pharmaceutical Health And Rational Use of Medicines (PHARM)
Committee
The PHARM committee is a multidisciplinary committee that provides expert advice to the
Australian Government Minister for Health and Ageing and the Department of Health and
Ageing on the National Strategy for Quality Use of Medicines. It also promotes and reviews
the National Strategy for Quality Use of Medicines and oversees its implementation, and
encourages quality use of medicines educational activities and programs.
Members have expertise in general practice, pharmacy, nursing, pharmaceutical industry,
consumer issues, health education and behavioural science and are appointed by the
Minister for Health and Ageing.
Australian Pharmaceutical Advisory Council (APAC)
APAC is a consultative forum that advises the Australian Government on a wide range of
medicines policy issues. The Council includes representatives of peak health professions
(pharmacy, medical and nursing), pharmaceutical industry, consumer and medical
organisations, as well as government members with an interest in implementing Australia’s
National Medicines Policy.
National Prescribing Service (NPS)
NPS is a non-profit organisation, independent of government and the pharmaceutical
industry, operating since 1999 and funded by the Australian Government Department of
Health and Ageing. Its members represent health professionals, government, industry and
consumers.
The NPS aims: to achieve better health and economic outcomes as a result of quality use of
medicines; to improve the quality of prescribing and use of medicines by using interventions
designed to change prescribing behaviour and providing independent, reliable, timely
information about medicines to prescribers and consumers; and to build awareness and
competence among health professionals and the community that will lead to quality use of
medicines, including choices between medicines and other approaches to health problems.
71
Pharmaceutical Benefits Advisory Committee (PBAC)
PBAC is an independent statutory body established in 1954 to make recommendations and
advise the Australian Government Minister of Health and Ageing on which medicines
should be made available as part of the PBS. It considers the effectiveness and cost of a
proposed benefit compared to alternative therapies. The committee recommends maximum
quantities to be dispensed and repeats of the medicine. It may also recommend restrictions
to the indications for which PBS subsidy is available.
Therapeutic Goods Administration (TGA)
TGA is part of the Australian Government Department of Health and Ageing and is
responsible for ensuring that therapeutic goods available in Australia are of an acceptable
standard and that Australians have timely access to therapeutic advances. It controls the
supply of therapeutic goods through pre-market assessment, licensing of manufacturers and
post-market surveillance.
National Institute of Clinical Studies (NICS)
NICS, now part of the National Health Medical and Research Council, is Australia’s national
agency for improving health care by helping close gaps between best available evidence and
current clinical practice. It was established by the Australian Government in 2000. NICS
works with researchers, practitioners and other stakeholders to establish where gaps exist;
raises awareness of these gaps; and supports health professionals to understand and
overcome the barriers to applying evidence within Australian health care settings.
72
Glossary
Angiotensin-convertingenzyme (ACE) inhibitors
Medicines used to treat people with high blood pressure or
heart failure. They limit the progressive enlargement of the
heart that can occur after a heart attack and relieve heart
failure symptoms. If given early during a heart attack, they
can reduce the risk of death.
Acute coronary syndrome
Describes acute myocardial infarction (heart attack) or
unstable angina when they first present as a clinical
emergency with chest pain or other features.
Adverse event
An event or circumstance in which a person receiving health
care was harmed.
Agents acting on renin–
angiotensin system
Includes ACE inhibitors and angiotensin II antagonists.
Angina
A short episode of chest pain that occurs when the heart has a
temporary deficiency in its blood supply due to a severe, but
incomplete, blockage in one of its arteries.
Angiotensin II antagonists
Medicines used to treat people with high blood pressure or
heart failure. They also reduce the progression of kidney
disease in people with diabetes, high blood pressure and
protein leaking from the kidneys into the urine.
Antiarrhythmics
Medicines given to restore the normal heart rhythm or prevent
life-threatening abnormal heart rhythms (arrhythmias).
Antithrombotic agents
Medicines that prevent the formation of clots, which could
block blood vessels, by interfering with the clotting process.
They are given to certain patients with heart disease, such as
those with atrial fibrillation, after some heart attacks, or to
those with severe heart failure, with ischaemic stroke or
peripheral vascular disease (except previous embolism) to
lower their risk of subsequent disease. They are also
commonly used during percutaneous coronary intervention.
Arrhythmia
A disturbed rhythm of the heart beat—either too fast, too slow
or irregular.
Atrial fibrillation
A condition marked by an irregular rapid heart beat. It arises
because the heart’s collecting chambers (atria) stop beating
rhythmically and quiver uselessly (fibrillate).
Beta-blocking agents
Medicines used to treat patients with high blood pressure, but
they also have other important uses. Through their lowering
of blood pressure, these medicines prevent strokes and heart
attacks. Also, in people with angina or history of heart attack,
beta-blockers can reduce pain and deaths, and prevent further
heart attacks. Certain beta-blockers are often used in the
treatment of heart failure.
Calcium-channel blockers
Medicines effective in reducing blood pressure and angina.
73
Cardiovascular disease
Any disease of the heart (cardio) and blood vessels (vascular).
Includes myocardial infarction, angina, heart failure, stroke
and peripheral vascular disease. Also known as circulatory
disease.
Cerebrovascular disease
Cerebrovascular disease refers to any disorder of the blood
vessels supplying the brain or its covering membranes.
Circulatory disease
See cardiovascular disease.
Complementary
medicines
Also known as traditional or alternative medicines. They
include vitamins, minerals, nutritional supplements, and
herbal, aromatherapy and homeopathic products.
Coronary heart disease
Also known as ischaemic heart disease, it is the most common
form of heart disease. There are two major clinical forms: acute
myocardial infarction and angina.
Chronic disease
Condition with a long development period, some of which
may have no symptoms; prolonged course of illness, perhaps
leading to other health complications; and associated
functional impairment or disability.
Diabetes
Condition in which the body cannot properly use its main
energy source: the sugar glucose.
Diuretics
Medicines effective in reducing blood pressure, which reduces
the occurrence of strokes and heart disease. Diuretics are also
helpful for treating symptoms in people with heart failure.
Drug-adverse event
Medicine problem that results in harm to the patient.
Harm
Includes disease, injury, suffering, disability and death.
Heart attack
See myocardial infarction.
Heart failure
Heart failure occurs when the heart functions less effectively
in pumping blood around the body. It can result from a
variety of diseases and conditions that impair or overload the
heart, notably heart attack, high blood pressure or a damaged
heart valve. People with mild heart failure may have few
symptoms, but in more severe cases it can result in chronic
tiredness, reduced capacity to undertake physical activity and
shortness of breath.
Hypertension
High blood pressure.
Myocardial infarction
Often referred as heart attack, it is a life threatening event that
occurs when a blood vessel supplying the heart itself is
suddenly blocked completely, threatening to disrupt the heart
and its functions. Strictly, myocardial infarction refers only to
those heart attacks that have caused death of some heart
muscle.
Over-the-counter
medicines
Private, non-prescription medicinal preparations that can be
purchased from pharmacies, supermarkets and other retail
outlets.
Peripheral vascular
disease
Pain in the legs due to inadequate blood supply.
74
Plain ACE inhibitors
ACE inhibitors without a diuretic component.
Prescription medicines
Pharmaceutical medicines available only on prescription of a
registered medical practitioner and available only from
pharmacies.
Serum-lipid-reducing
agents
Also known as lipid-lowering medicines, they are effective in
preventing heart attacks and reducing coronary heart disease
deaths. HMG CoA reductase inhibitors (statins), resin binders,
nicotinic acid, fibrates and probucol all reduce blood LDL
cholesterol and possibly increase HDL cholesterol to varying
degrees, with statins being the most effective. They also have
varying effects in lowering blood triglycerides.
Statin
See serum-lipid-reducing agents.
Stroke
Stroke occurs when a blood vessel to the brain is suddenly
blocked or bleeds. This may result in part of the brain dying
due to the lack of blood, leading to a loss of brain function or
impairment in a range of activities including movement,
thinking and communication, and may lead to death.
Tachycardia
An abnormally fast heart beat.
Thrombosis
Clotting of blood within a blood vessel.
75
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List of tables
Table 1:
Prevalence of selected conditions among Australians, 2004–05 ...................................5
Table 2:
Indications for medicines used in cardiovascular disease.............................................6
Table 3:
Top ten medicines by defined daily dose/1,000 population/day, 2005 ...................11
Table 4:
Medicines used for cardiovascular conditions, 2004–05..............................................19
Table 5:
Medicines prescribed or supplied by GPs for specific problems, 2000–06 ...............20
Table 6:
Characteristics of the patients studied ...........................................................................31
Table 7:
Prescriptions supplied by region of patient residence.................................................32
Table 8:
Persistence with medicines ..............................................................................................33
Table 9:
Newly prescribed patients dispensed one prescription only......................................34
Table 10: Medicines with blood-pressure-lowering effect prescribed........................................36
Table 11: Patients with hypertension and a coexisting condition prescribed bloodpressure-lowering medicines with favourable or unfavourable effects
on coexisting conditions ...................................................................................................37
Table 12: Quality practices in management of coronary heart disease among
participants in Australian primary care collaboratives ...............................................39
Table 13: Deaths with adverse effects of medicines used to prevent or treat
cardiovascular disease, 2004 ............................................................................................41
Table 14: Hospitalisations with adverse effects of medicines used to prevent or treat
cardiovascular disease, 2003–04 and 2004–05 ...............................................................42
Table 15: Top ten prescription medicines by cost to the Australian Government, 2005..........45
Table A1: Supply of cardiovascular medicines in selected OECD countries, 2004....................52
Table A2: Persistence with medicines by region of patient residence .........................................53
Table A3: Prescriptions supplied to newly prescribed patients by socioeconomic level..........54
Table A4: Persistence with medicines by level of socioeconomic disadvantage .......................54
Table A5: Government expenditure on selected medicines (constant prices), 2001–05............55
Tables e1–e8 are available in electronic form at <www.aihw.gov.au>.
80
List of figures
Figure 1:
Supply of medicines with blood-pressure-lowering effect in the community ......13
Figure 2:
Supply of serum-lipid-reducing agents in the community ......................................13
Figure 3:
Supply of antithrombotic agents in the community ..................................................14
Figure 4:
Supply of cardiac therapy medicines in the community ..........................................14
Figure 5:
Medicines with blood-pressure-lowering effect prescribed or supplied by GPs ..16
Figure 6:
Serum-lipid-reducing agents prescribed or supplied by GPs ..................................16
Figure 7:
Antithrombotic agents prescribed or supplied by GPs .............................................17
Figure 8:
Cardiac therapy medicines prescribed or supplied by GPs......................................17
Figure 9:
Medicines prescribed or supplied by GPs in managing hypertension ...................21
Figure 10: Medicines prescribed or supplied by GPs in managing lipid disorders.................22
Figure 11: Medicines prescribed or supplied by GPs in managing diabetes ............................22
Figure 12: Medicines prescribed or supplied by GPs in managing ischaemic heart disease .23
Figure 13: Medicines prescribed or supplied by GPs in managing heart failure .....................24
Figure 14: Medicines prescribed or supplied by GPs in managing arrhythmias.....................25
Figure 15: Medicines prescribed or supplied by GPs in managing stroke................................26
Figure 16: Medicines prescribed or supplied by GPs in managing peripheral vascular
disease ..............................................................................................................................26
Figure 17: Government expenditure on medicines to prevent and treat cardiovascular
disease, 2001–05...............................................................................................................46
Figure 18: Government expenditure on cardiovascular medicines by class, 2001–05.............47
Figure 19: Government expenditure on blood and blood-forming organs medicines by
class, 2001–05 ...................................................................................................................47
Figure A1: Persistence with HMG COA reductase inhibitors (statins) ......................................56
Figure A2: Persistence with selected medicines with blood-pressure-lowering effect ............56
Figure A3: Persistence with antithrombotic agents.......................................................................57
81